Provider Demographics
NPI:1295289940
Name:FUQUA, MICHELLE LYNN (PT)
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:LYNN
Last Name:FUQUA
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:MICHELLE
Other - Middle Name:LYNN
Other - Last Name:HOFFERBER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:4808 S 109TH EAST AVE
Mailing Address - Street 2:SUITE 100
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74146-5822
Mailing Address - Country:US
Mailing Address - Phone:918-392-1482
Mailing Address - Fax:918-392-7063
Practice Address - Street 1:4808 S 109TH EAST AVE
Practice Address - Street 2:SUITE 100
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74146-5822
Practice Address - Country:US
Practice Address - Phone:918-392-1482
Practice Address - Fax:918-392-7063
Is Sole Proprietor?:No
Enumeration Date:2016-08-11
Last Update Date:2016-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK5177225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist