Provider Demographics
NPI:1417610346
Name:GUTIERREZ, TIANNA DENISE
Entity Type:Individual
Prefix:
First Name:TIANNA
Middle Name:DENISE
Last Name:GUTIERREZ
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 1:1105 ELMHURST ST
Mailing Address - Street 2:
Mailing Address - City:MOORE
Mailing Address - State:OK
Mailing Address - Zip Code:73160-5831
Mailing Address - Country:US
Mailing Address - Phone:405-740-6192
Mailing Address - Fax:
Practice Address - Street 1:1105 ELMHURST ST
Practice Address - Street 2:
Practice Address - City:MOORE
Practice Address - State:OK
Practice Address - Zip Code:73160-5831
Practice Address - Country:US
Practice Address - Phone:405-740-6192
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-18
Last Update Date:2021-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator