Provider Demographics
NPI:1316534431
Name:FOSSARD, KELLY (DPT)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:FOSSARD
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:800 E ALBUQUERQUE ST
Mailing Address - Street 2:
Mailing Address - City:BROKEN ARROW
Mailing Address - State:OK
Mailing Address - Zip Code:74011-7245
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:7401 RIVERSIDE PKWY
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74136-5044
Practice Address - Country:US
Practice Address - Phone:918-417-1906
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-12-22
Last Update Date:2020-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK5474225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist