Provider Demographics
NPI:1124229711
Name:WALLEN, BRITNY (PTA)
Entity Type:Individual
Prefix:
First Name:BRITNY
Middle Name:
Last Name:WALLEN
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1825 N 189 RD
Mailing Address - Street 2:
Mailing Address - City:MOUNDS
Mailing Address - State:OK
Mailing Address - Zip Code:74047-6221
Mailing Address - Country:US
Mailing Address - Phone:918-756-9211
Mailing Address - Fax:
Practice Address - Street 1:1825 N 189 RD
Practice Address - Street 2:
Practice Address - City:MOUNDS
Practice Address - State:OK
Practice Address - Zip Code:74047-6221
Practice Address - Country:US
Practice Address - Phone:918-756-9211
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK1423225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant