Provider Demographics
NPI:1578123022
Name:COQUILLETTE, TRACY LYNE
Entity Type:Individual
Prefix:
First Name:TRACY
Middle Name:LYNE
Last Name:COQUILLETTE
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 1:28788 N 3964 RD
Mailing Address - Street 2:
Mailing Address - City:OCHELATA
Mailing Address - State:OK
Mailing Address - Zip Code:74051-2049
Mailing Address - Country:US
Mailing Address - Phone:620-515-3210
Mailing Address - Fax:
Practice Address - Street 1:28788 N 3964 RD
Practice Address - Street 2:
Practice Address - City:OCHELATA
Practice Address - State:OK
Practice Address - Zip Code:74051-2049
Practice Address - Country:US
Practice Address - Phone:620-515-3210
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-06-17
Last Update Date:2019-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator