Provider Demographics
NPI:1376716100
Name:KELLEY, GINA NICOLE (PTA)
Entity Type:Individual
Prefix:
First Name:GINA
Middle Name:NICOLE
Last Name:KELLEY
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 1:1201 S DOUGLAS BLVD
Mailing Address - Street 2:SUITE I
Mailing Address - City:MIDWEST CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73130-5239
Mailing Address - Country:US
Mailing Address - Phone:405-610-8090
Mailing Address - Fax:
Practice Address - Street 1:1201 S DOUGLAS BLVD
Practice Address - Street 2:SUITE I
Practice Address - City:MIDWEST CITY
Practice Address - State:OK
Practice Address - Zip Code:73130-5239
Practice Address - Country:US
Practice Address - Phone:405-610-8090
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-04-13
Last Update Date:2008-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK815225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant