Provider Demographics
NPI:1043732787
Name:OGLESBY, LANDRE TATUM (ATC)
Entity type:Individual
Prefix:
First Name:LANDRE
Middle Name:TATUM
Last Name:OGLESBY
Suffix:
Gender:F
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13616 RED BUD RD
Mailing Address - Street 2:
Mailing Address - City:CHOCTAW
Mailing Address - State:OK
Mailing Address - Zip Code:73020-7166
Mailing Address - Country:US
Mailing Address - Phone:405-250-0550
Mailing Address - Fax:405-250-0550
Practice Address - Street 1:100 N UNIVERSITY DR # 190
Practice Address - Street 2:
Practice Address - City:EDMOND
Practice Address - State:OK
Practice Address - Zip Code:73034-5207
Practice Address - Country:US
Practice Address - Phone:405-974-2188
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-07-14
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
20000298282255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
Provider Identifiers
StateIdentifier IDID TypeIssuer
73898OtherBOARD OF CERTIFICATION