Provider Demographics
NPI:1659921948
Name:OUTLAW, SEQUOYHA RAECHELLE (PT)
Entity Type:Individual
Prefix:
First Name:SEQUOYHA
Middle Name:RAECHELLE
Last Name:OUTLAW
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:176C W UNIVERSITY PKWY # C
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:TN
Mailing Address - Zip Code:38305-1616
Mailing Address - Country:US
Mailing Address - Phone:731-300-4950
Mailing Address - Fax:731-300-4951
Practice Address - Street 1:176C W UNIVERSITY PKWY # C
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:TN
Practice Address - Zip Code:38305-1616
Practice Address - Country:US
Practice Address - Phone:731-300-4950
Practice Address - Fax:731-300-4951
Is Sole Proprietor?:No
Enumeration Date:2019-09-18
Last Update Date:2019-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN12410208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation