Provider Demographics
NPI:1497339733
Name:AGNEW, LESLIE NICOLE (PTA)
Entity Type:Individual
Prefix:
First Name:LESLIE
Middle Name:NICOLE
Last Name:AGNEW
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:LESLIE
Other - Middle Name:NICOLE
Other - Last Name:DAY
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PTA
Mailing Address - Street 1:1392 E 171ST ST N
Mailing Address - Street 2:
Mailing Address - City:SKIATOOK
Mailing Address - State:OK
Mailing Address - Zip Code:74070-3121
Mailing Address - Country:US
Mailing Address - Phone:918-798-6733
Mailing Address - Fax:
Practice Address - Street 1:1815 E SKELLY DR
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74105-5949
Practice Address - Country:US
Practice Address - Phone:918-747-4193
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-05-12
Last Update Date:2021-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK1449225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
OKPTA-1449OtherOKLAHOMA PTA LICENSURE