Provider Demographics
NPI:1568896876
Name:MCANALLY, KRISTINA (PT)
Entity Type:Individual
Prefix:
First Name:KRISTINA
Middle Name:
Last Name:MCANALLY
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 3675
Mailing Address - Street 2:
Mailing Address - City:SHAWNEE
Mailing Address - State:OK
Mailing Address - Zip Code:74802-3675
Mailing Address - Country:US
Mailing Address - Phone:405-214-0300
Mailing Address - Fax:405-214-0301
Practice Address - Street 1:2506 N HARRISON ST
Practice Address - Street 2:
Practice Address - City:SHAWNEE
Practice Address - State:OK
Practice Address - Zip Code:74804-3131
Practice Address - Country:US
Practice Address - Phone:405-214-0300
Practice Address - Fax:405-214-0301
Is Sole Proprietor?:Yes
Enumeration Date:2013-08-23
Last Update Date:2021-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK4687225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200512600AMedicaid
OK4687OtherLICENSE
OK1568896876OtherNPI
OK4687OtherLICENSE