Provider Demographics
NPI:1912601071
Name:DALLIS, TAMALA (PRSS)
Entity Type:Individual
Prefix:
First Name:TAMALA
Middle Name:
Last Name:DALLIS
Suffix:
Gender:F
Credentials:PRSS
Other - Prefix:
Other - First Name:TAMMY
Other - Middle Name:
Other - Last Name:DALLIS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:206 CHIEF STAN WAITE DR
Mailing Address - Street 2:
Mailing Address - City:CATOOSA
Mailing Address - State:OK
Mailing Address - Zip Code:74015-2129
Mailing Address - Country:US
Mailing Address - Phone:918-822-2669
Mailing Address - Fax:
Practice Address - Street 1:6333 E SKELLY DR
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74135-6106
Practice Address - Country:US
Practice Address - Phone:918-664-4224
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-03-30
Last Update Date:2023-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist