Provider Demographics
NPI:1184106577
Name:PEOPLES, KRYSTAL (PTA)
Entity type:Individual
Prefix:
First Name:KRYSTAL
Middle Name:
Last Name:PEOPLES
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 1:39 LAKE MEADOW LOOP RD
Mailing Address - Street 2:
Mailing Address - City:DURANT
Mailing Address - State:OK
Mailing Address - Zip Code:74701-8057
Mailing Address - Country:US
Mailing Address - Phone:903-271-0410
Mailing Address - Fax:
Practice Address - Street 1:1600 N WASHINGTON AVE
Practice Address - Street 2:
Practice Address - City:DURANT
Practice Address - State:OK
Practice Address - Zip Code:74701-2128
Practice Address - Country:US
Practice Address - Phone:580-740-0205
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-31
Last Update Date:2021-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2134721208100000X
OK2834225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
No208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation