Provider Demographics
NPI:1093498776
Name:FUENTES, LESLIE CATHERINE (PTA)
Entity Type:Individual
Prefix:
First Name:LESLIE
Middle Name:CATHERINE
Last Name:FUENTES
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:LESLIE
Other - Middle Name:
Other - Last Name:KELLOGG
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PTA
Mailing Address - Street 1:2652 COLES CREEK LN
Mailing Address - Street 2:
Mailing Address - City:YUKON
Mailing Address - State:OK
Mailing Address - Zip Code:73099-2360
Mailing Address - Country:US
Mailing Address - Phone:405-431-9347
Mailing Address - Fax:
Practice Address - Street 1:7707 W BRITTON RD
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73132-1512
Practice Address - Country:US
Practice Address - Phone:405-720-7200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-08-09
Last Update Date:2023-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK2163225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant