Provider Demographics
NPI:1972058196
Name:CLEMMER, ANDREA (PTA)
Entity Type:Individual
Prefix:
First Name:ANDREA
Middle Name:
Last Name:CLEMMER
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11649 S 252ND WEST AVE
Mailing Address - Street 2:
Mailing Address - City:SAPULPA
Mailing Address - State:OK
Mailing Address - Zip Code:74066-7980
Mailing Address - Country:US
Mailing Address - Phone:918-637-3136
Mailing Address - Fax:
Practice Address - Street 1:11649 S 252ND WEST AVE
Practice Address - Street 2:
Practice Address - City:SAPULPA
Practice Address - State:OK
Practice Address - Zip Code:74066-7980
Practice Address - Country:US
Practice Address - Phone:918-637-3136
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-17
Last Update Date:2016-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK2499225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant