Provider Demographics
NPI:1669014494
Name:KIZZIA, GARRETT (ATC)
Entity Type:Individual
Prefix:
First Name:GARRETT
Middle Name:
Last Name:KIZZIA
Suffix:
Gender:M
Credentials:ATC
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 25
Mailing Address - Street 2:
Mailing Address - City:BRAGGS
Mailing Address - State:OK
Mailing Address - Zip Code:74423
Mailing Address - Country:US
Mailing Address - Phone:580-235-6364
Mailing Address - Fax:
Practice Address - Street 1:700 COLLEGE RD
Practice Address - Street 2:
Practice Address - City:WARNER
Practice Address - State:OK
Practice Address - Zip Code:74469-2204
Practice Address - Country:US
Practice Address - Phone:918-463-6261
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-10-14
Last Update Date:2019-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK8662255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK866OtherMEDICAL LICENSE NUMBER