Provider Demographics
NPI:1083211742
Name:GAGE, LAWANNA
Entity Type:Individual
Prefix:
First Name:LAWANNA
Middle Name:
Last Name:GAGE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1937 TREAT DR
Mailing Address - Street 2:
Mailing Address - City:MIDWEST CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73110-2574
Mailing Address - Country:US
Mailing Address - Phone:405-496-2499
Mailing Address - Fax:
Practice Address - Street 1:7901 NE 10TH ST STE A209
Practice Address - Street 2:
Practice Address - City:MIDWEST CITY
Practice Address - State:OK
Practice Address - Zip Code:73110-3689
Practice Address - Country:US
Practice Address - Phone:405-496-2499
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-06
Last Update Date:2020-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK172283225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist