Provider Demographics
NPI:1417103508
Name:CORDELL, KYLIE LARAE (PT)
Entity Type:Individual
Prefix:
First Name:KYLIE
Middle Name:LARAE
Last Name:CORDELL
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 14547
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73113-0547
Mailing Address - Country:US
Mailing Address - Phone:405-810-2902
Mailing Address - Fax:405-810-2905
Practice Address - Street 1:6801 N CLASSEN BLVD
Practice Address - Street 2:SUITE B
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73116-7205
Practice Address - Country:US
Practice Address - Phone:405-810-2902
Practice Address - Fax:405-810-2905
Is Sole Proprietor?:No
Enumeration Date:2008-08-08
Last Update Date:2011-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK4138225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200271740AMedicaid
OKOK404494Medicare PIN
OK200271740AMedicaid
OKOK401202Medicare PIN