Healthcare Provider Details

I. General information

NPI: 1811432032
Provider Name (Legal Business Name): SANDRA NICHOLS PT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/23/2016
Last Update Date: 12/23/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

711 N 5TH ST
JENKS OK
74037-3343
US

IV. Provider business mailing address

1733 S XANTHUS AVE
TULSA OK
74104-5323
US

V. Phone/Fax

Practice location:
  • Phone: 918-299-8508
  • Fax:
Mailing address:
  • Phone: 661-350-4473
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number5218
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: