Healthcare Provider Details

I. General information

NPI: 1114130861
Provider Name (Legal Business Name): KIM ANNE HASLETT PTA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/08/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3000 SOUTH ELM PLACE
BROKEN ARROW OK
74012
US

IV. Provider business mailing address

11664 SOUTH 252 EAST AVE
BROKEN ARROW OK
74014
US

V. Phone/Fax

Practice location:
  • Phone: 918-451-5143
  • Fax: 918-451-5287
Mailing address:
  • Phone: 918-486-5821
  • Fax: 918-451-5287

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License NumberTA 591
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: