Provider Demographics
NPI:1255113478
Name:AXTON, COURTNEY
Entity type:Individual
Prefix:
First Name:COURTNEY
Middle Name:
Last Name:AXTON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:757 BATTIEST PICKENS RD
Mailing Address - Street 2:
Mailing Address - City:BROKEN BOW
Mailing Address - State:OK
Mailing Address - Zip Code:74728-5198
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:757 BATTIEST PICKENS RD
Practice Address - Street 2:
Practice Address - City:BROKEN BOW
Practice Address - State:OK
Practice Address - Zip Code:74728-5198
Practice Address - Country:US
Practice Address - Phone:903-701-6939
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-10-23
Last Update Date:2023-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK2354225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant