Provider Demographics
NPI:1912275157
Name:SETIAWAN, LANNY
Entity Type:Individual
Prefix:
First Name:LANNY
Middle Name:
Last Name:SETIAWAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6212 E 72ND STREET
Mailing Address - Street 2:APT 829
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74136-6945
Mailing Address - Country:US
Mailing Address - Phone:918-859-4035
Mailing Address - Fax:
Practice Address - Street 1:2448 E 81ST STREET
Practice Address - Street 2:SUITE 4824
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74137-4320
Practice Address - Country:US
Practice Address - Phone:918-392-7875
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-12-02
Last Update Date:2011-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner