Provider Demographics
NPI:1477324432
Name:BOVARD, BAILEY MARIEA
Entity Type:Individual
Prefix:
First Name:BAILEY
Middle Name:MARIEA
Last Name:BOVARD
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 1:513 N SHANNON WAY
Mailing Address - Street 2:
Mailing Address - City:MUSTANG
Mailing Address - State:OK
Mailing Address - Zip Code:73064-2347
Mailing Address - Country:US
Mailing Address - Phone:417-543-4822
Mailing Address - Fax:
Practice Address - Street 1:13200 S MAY AVE
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73170-4541
Practice Address - Country:US
Practice Address - Phone:405-252-9107
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-01-09
Last Update Date:2024-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK6147225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist