Provider Demographics
NPI:1609442508
Name:TUCKER, GABRIELLE RENEE (PTA)
Entity Type:Individual
Prefix:
First Name:GABRIELLE
Middle Name:RENEE
Last Name:TUCKER
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21712 W DUNCAN RD
Mailing Address - Street 2:
Mailing Address - City:HASKELL
Mailing Address - State:OK
Mailing Address - Zip Code:74436-5019
Mailing Address - Country:US
Mailing Address - Phone:918-927-2477
Mailing Address - Fax:
Practice Address - Street 1:114 W 7TH ST
Practice Address - Street 2:
Practice Address - City:OKMULGEE
Practice Address - State:OK
Practice Address - Zip Code:74447-5052
Practice Address - Country:US
Practice Address - Phone:918-756-3330
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-01
Last Update Date:2021-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK3365225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant