MEDICARE: SHELLY RANAE WADDLE OTA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	224Z00000X	Occupational Therapy Assistant	473	OK

General Provider Information

NPI Number	:	1730386756
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SHELLY RANAE WADDLE OTA

Provider Business Mailing Address
First Line	:	1013 S.W. 128 ST
Second Line	:
City	:	OKC
State	:	OK
Zip	:	73170
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1013 SW 128TH ST
Second Line	:
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73170-6951
Country	:	US
Telephone Number	:	405-691-3418
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/02/2007
Last Update Date	:	07/08/2007

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