Provider Demographics
NPI:1184696023
Name:WALLACE, KELLY (RPT)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:WALLACE
Suffix:
Gender:F
Credentials:RPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13390 NE 23RD ST
Mailing Address - Street 2:
Mailing Address - City:CHOCTAW
Mailing Address - State:OK
Mailing Address - Zip Code:73020-8622
Mailing Address - Country:US
Mailing Address - Phone:405-769-5555
Mailing Address - Fax:405-769-5558
Practice Address - Street 1:13390 NE 23RD ST
Practice Address - Street 2:
Practice Address - City:CHOCTAW
Practice Address - State:OK
Practice Address - Zip Code:73020-8622
Practice Address - Country:US
Practice Address - Phone:405-769-5555
Practice Address - Fax:405-769-5558
Is Sole Proprietor?:No
Enumeration Date:2006-02-05
Last Update Date:2015-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKPT2460225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200552760AMedicaid
OK277255ZJO6Medicare Oscar/Certification