Provider Demographics
NPI:1235972449
Name:PETCOFF, PRESLEY LOUISE
Entity type:Individual
Prefix:MRS
First Name:PRESLEY
Middle Name:LOUISE
Last Name:PETCOFF
Suffix:
Gender:F
Credentials:
Other - Prefix:MRS
Other - First Name:PRESLEY
Other - Middle Name:LOUISE
Other - Last Name:OSBORN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:16005 E 112TH ST N
Mailing Address - Street 2:
Mailing Address - City:OWASSO
Mailing Address - State:OK
Mailing Address - Zip Code:74055-5039
Mailing Address - Country:US
Mailing Address - Phone:918-606-0243
Mailing Address - Fax:
Practice Address - Street 1:1111 W 17TH ST
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74107-1886
Practice Address - Country:US
Practice Address - Phone:918-582-1972
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-06-15
Last Update Date:2024-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program