Provider Demographics
NPI:1376785303
Name:BRANNON, ANDRA LEA (PTA)
Entity Type:Individual
Prefix:
First Name:ANDRA
Middle Name:LEA
Last Name:BRANNON
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:ANDRA
Other - Middle Name:LEA
Other - Last Name:MOONEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1089 S JEFFERSON ST
Mailing Address - Street 2:
Mailing Address - City:WELCH
Mailing Address - State:OK
Mailing Address - Zip Code:74369-9309
Mailing Address - Country:US
Mailing Address - Phone:918-788-3142
Mailing Address - Fax:
Practice Address - Street 1:1505 E STEVE OWENS BLVD
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:OK
Practice Address - Zip Code:74354-7917
Practice Address - Country:US
Practice Address - Phone:918-542-4101
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-04-06
Last Update Date:2009-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK938225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant