Provider Demographics
NPI:1396395125
Name:BREA TAVAREZ, ASHLEY ALTAGRACIA
Entity Type:Individual
Prefix:
First Name:ASHLEY
Middle Name:ALTAGRACIA
Last Name:BREA TAVAREZ
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 1:9501 S I 35 SERVICE RD APT 519
Mailing Address - Street 2:
Mailing Address - City:MOORE
Mailing Address - State:OK
Mailing Address - Zip Code:73160-3146
Mailing Address - Country:US
Mailing Address - Phone:347-995-7868
Mailing Address - Fax:
Practice Address - Street 1:420 SW 10TH ST
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73109-5610
Practice Address - Country:US
Practice Address - Phone:405-236-0701
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-09-13
Last Update Date:2019-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator