Provider Demographics
NPI:1083256176
Name:TATOM, HALEY LYNN
Entity Type:Individual
Prefix:
First Name:HALEY
Middle Name:LYNN
Last Name:TATOM
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:PO BOX 84
Mailing Address - Street 2:
Mailing Address - City:GARDEN PLAIN
Mailing Address - State:KS
Mailing Address - Zip Code:67050-0084
Mailing Address - Country:US
Mailing Address - Phone:316-706-2437
Mailing Address - Fax:
Practice Address - Street 1:7821 S UNION AVE APT 323
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74132-2737
Practice Address - Country:US
Practice Address - Phone:316-706-2437
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-10-10
Last Update Date:2022-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS15-02580363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant