Provider Demographics
NPI:1568221265
Name:NOVOA, KAITLIN VICTORIA (LMT)
Entity Type:Individual
Prefix:
First Name:KAITLIN
Middle Name:VICTORIA
Last Name:NOVOA
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:105 BRITTANY
Mailing Address - Street 2:
Mailing Address - City:POCOLA
Mailing Address - State:OK
Mailing Address - Zip Code:74902-2362
Mailing Address - Country:US
Mailing Address - Phone:918-839-7473
Mailing Address - Fax:
Practice Address - Street 1:1150 S WALDRON RD
Practice Address - Street 2:
Practice Address - City:FORT SMITH
Practice Address - State:AR
Practice Address - Zip Code:72903-2583
Practice Address - Country:US
Practice Address - Phone:479-452-4433
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-03-15
Last Update Date:2024-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR3804225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist