Provider Demographics
NPI:1962269860
Name:KOMLODI, TATUM BREANNE
Entity type:Individual
Prefix:MRS
First Name:TATUM
Middle Name:BREANNE
Last Name:KOMLODI
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:TATUM
Other - Middle Name:BREANNE
Other - Last Name:HOGENES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:401 EYLER LN
Mailing Address - Street 2:
Mailing Address - City:STILLWATER
Mailing Address - State:OK
Mailing Address - Zip Code:74074-2821
Mailing Address - Country:US
Mailing Address - Phone:480-290-3983
Mailing Address - Fax:
Practice Address - Street 1:401 EYLER LN
Practice Address - Street 2:
Practice Address - City:STILLWATER
Practice Address - State:OK
Practice Address - Zip Code:74074-2821
Practice Address - Country:US
Practice Address - Phone:480-290-3983
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-03-06
Last Update Date:2024-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer