Provider Demographics
NPI:1649481789
Name:VANDERPOOL, KERI DAWN (PTA)
Entity type:Individual
Prefix:
First Name:KERI
Middle Name:DAWN
Last Name:VANDERPOOL
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:KERI
Other - Middle Name:DAWN
Other - Last Name:KULP
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PTA
Mailing Address - Street 1:1105 S MARINA DR
Mailing Address - Street 2:
Mailing Address - City:OOLOGAH
Mailing Address - State:OK
Mailing Address - Zip Code:74053-3284
Mailing Address - Country:US
Mailing Address - Phone:918-443-2026
Mailing Address - Fax:917-443-2026
Practice Address - Street 1:4815 S HARVARD AVE
Practice Address - Street 2:SUITE 455
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74135-3055
Practice Address - Country:US
Practice Address - Phone:918-712-7805
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKTA583225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant