Provider Demographics
NPI:1619187200
Name:WALLACE, KIRSTEN ANN (PT)
Entity Type:Individual
Prefix:
First Name:KIRSTEN
Middle Name:ANN
Last Name:WALLACE
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:18305 ENGLISH OAK LN
Mailing Address - Street 2:
Mailing Address - City:EDMOND
Mailing Address - State:OK
Mailing Address - Zip Code:73003-4051
Mailing Address - Country:US
Mailing Address - Phone:405-216-8731
Mailing Address - Fax:405-945-4501
Practice Address - Street 1:5300 N INDEPENDENCE AVE
Practice Address - Street 2:SUITE 100
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73112-5556
Practice Address - Country:US
Practice Address - Phone:405-945-4500
Practice Address - Fax:405-945-4501
Is Sole Proprietor?:No
Enumeration Date:2007-05-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKPT1940225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist