Provider Demographics
NPI:1770393670
Name:LEATHERMAN, LORI LYNN
Entity type:Individual
Prefix:
First Name:LORI
Middle Name:LYNN
Last Name:LEATHERMAN
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4320 S GARNETT RD APT 105
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74146-4246
Mailing Address - Country:US
Mailing Address - Phone:918-933-1571
Mailing Address - Fax:
Practice Address - Street 1:5330 E 31ST ST STE 1000
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74135-5010
Practice Address - Country:US
Practice Address - Phone:918-933-1571
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-01-13
Last Update Date:2025-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist