Provider Demographics
NPI:1972856474
Name:MAXWELL, TAMMY LYNN (PTA)
Entity Type:Individual
Prefix:MRS
First Name:TAMMY
Middle Name:LYNN
Last Name:MAXWELL
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 1:1141 9TH ST
Mailing Address - Street 2:
Mailing Address - City:ALVA
Mailing Address - State:OK
Mailing Address - Zip Code:73717-3127
Mailing Address - Country:US
Mailing Address - Phone:580-530-2387
Mailing Address - Fax:
Practice Address - Street 1:1141 9TH ST
Practice Address - Street 2:
Practice Address - City:ALVA
Practice Address - State:OK
Practice Address - Zip Code:73717-3127
Practice Address - Country:US
Practice Address - Phone:580-530-2387
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-10-22
Last Update Date:2012-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK1701225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant