Provider Demographics
NPI:1215201967
Name:BASHAM-TAYLOR, THERESA R (LPN)
Entity Type:Individual
Prefix:MRS
First Name:THERESA
Middle Name:R
Last Name:BASHAM-TAYLOR
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3518 E VIRGIN PL
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74115-3922
Mailing Address - Country:US
Mailing Address - Phone:918-665-2501
Mailing Address - Fax:918-665-3966
Practice Address - Street 1:5550 S GARNETT RD
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74146-6831
Practice Address - Country:US
Practice Address - Phone:918-665-2501
Practice Address - Fax:918-665-3966
Is Sole Proprietor?:Yes
Enumeration Date:2012-02-28
Last Update Date:2012-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK0050354164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse