Healthcare Provider Details

I. General information

NPI: 1538893029
Provider Name (Legal Business Name): KRISTIN J WIARD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/12/2022
Last Update Date: 07/12/2022
Certification Date: 07/12/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

711 N 5TH ST
JENKS OK
74037-3343
US

IV. Provider business mailing address

18617 E 46TH PL S
TULSA OK
74134-5501
US

V. Phone/Fax

Practice location:
  • Phone: 918-299-8508
  • Fax:
Mailing address:
  • Phone: 918-946-7100
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License Number1304
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: