Provider Demographics
NPI:1962151860
Name:VANN-MOORE, RAQUEL (COTA/L)
Entity type:Individual
Prefix:
First Name:RAQUEL
Middle Name:
Last Name:VANN-MOORE
Suffix:
Gender:F
Credentials:COTA/L
Other - Prefix:
Other - First Name:RAQUEL
Other - Middle Name:
Other - Last Name:VANN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:COTA/L
Mailing Address - Street 1:14143 E 91ST ST N
Mailing Address - Street 2:
Mailing Address - City:OWASSO
Mailing Address - State:OK
Mailing Address - Zip Code:74055-2760
Mailing Address - Country:US
Mailing Address - Phone:918-693-1750
Mailing Address - Fax:
Practice Address - Street 1:1320 NE 1ST PL
Practice Address - Street 2:
Practice Address - City:PRYOR
Practice Address - State:OK
Practice Address - Zip Code:74361-4406
Practice Address - Country:US
Practice Address - Phone:918-825-5311
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-03-20
Last Update Date:2022-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK1794224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant