Provider Demographics
NPI:1407031131
Name:PETTY, MECHELLE
Entity Type:Individual
Prefix:
First Name:MECHELLE
Middle Name:
Last Name:PETTY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2213 W XYLER ST
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74127-2228
Mailing Address - Country:US
Mailing Address - Phone:918-808-6083
Mailing Address - Fax:
Practice Address - Street 1:7133 RIVERSIDE PKWY
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74136-5053
Practice Address - Country:US
Practice Address - Phone:918-779-6777
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-12-31
Last Update Date:2021-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK3129225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist