Provider Demographics
NPI:1598533804
Name:MOORE, KELLEE MARIE
Entity Type:Individual
Prefix:
First Name:KELLEE
Middle Name:MARIE
Last Name:MOORE
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 1:118 E BROADWAY AVE
Mailing Address - Street 2:
Mailing Address - City:THOMAS
Mailing Address - State:OK
Mailing Address - Zip Code:73669-8321
Mailing Address - Country:US
Mailing Address - Phone:580-661-3517
Mailing Address - Fax:580-661-3528
Practice Address - Street 1:118 E BROADWAY AVE
Practice Address - Street 2:
Practice Address - City:THOMAS
Practice Address - State:OK
Practice Address - Zip Code:73669-8321
Practice Address - Country:US
Practice Address - Phone:580-661-3517
Practice Address - Fax:580-661-3528
Is Sole Proprietor?:Yes
Enumeration Date:2023-12-15
Last Update Date:2023-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK3117225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant