Provider Demographics
NPI:1841251311
Name:MOORE, HOLLY LANELL (PT)
Entity type:Individual
Prefix:MS
First Name:HOLLY
Middle Name:LANELL
Last Name:MOORE
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6904 E RENO AVE
Mailing Address - Street 2:
Mailing Address - City:MIDWEST CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73110-2152
Mailing Address - Country:US
Mailing Address - Phone:405-610-2488
Mailing Address - Fax:405-610-2484
Practice Address - Street 1:825 N BROADWAY AVE
Practice Address - Street 2:SUITE 400
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73102-6012
Practice Address - Country:US
Practice Address - Phone:405-609-3600
Practice Address - Fax:405-605-8638
Is Sole Proprietor?:No
Enumeration Date:2006-03-31
Last Update Date:2009-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKPT 2909225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK243700302Medicare PIN