Provider Demographics
NPI:1932428265
Name:DAVIS, DEANNA ILENE (LPTA)
Entity Type:Individual
Prefix:
First Name:DEANNA
Middle Name:ILENE
Last Name:DAVIS
Suffix:
Gender:F
Credentials:LPTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1503 CLAYTON AVE
Mailing Address - Street 2:
Mailing Address - City:POTEAU
Mailing Address - State:OK
Mailing Address - Zip Code:74953-4102
Mailing Address - Country:US
Mailing Address - Phone:918-647-9026
Mailing Address - Fax:918-647-8968
Practice Address - Street 1:1503 CLAYTON AVE
Practice Address - Street 2:
Practice Address - City:POTEAU
Practice Address - State:OK
Practice Address - Zip Code:74953-4102
Practice Address - Country:US
Practice Address - Phone:918-647-9026
Practice Address - Fax:918-647-8968
Is Sole Proprietor?:No
Enumeration Date:2010-05-26
Last Update Date:2010-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK744225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant