Provider Demographics
NPI:1255941969
Name:TAKYI-MICAH, TIERRA LASHAWN FULTZ (PT, DPT)
Entity type:Individual
Prefix:
First Name:TIERRA
Middle Name:LASHAWN FULTZ
Last Name:TAKYI-MICAH
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:TIERRA
Other - Middle Name:LASHAWN
Other - Last Name:FULTZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT, DPT
Mailing Address - Street 1:5009 AVION CT
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73135-5090
Mailing Address - Country:US
Mailing Address - Phone:918-809-4228
Mailing Address - Fax:
Practice Address - Street 1:309 SW 59TH ST STE 305
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73109-8324
Practice Address - Country:US
Practice Address - Phone:405-355-3239
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-06
Last Update Date:2020-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK5789225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist