Healthcare Provider Details

I. General information

NPI: 1124959606
Provider Name (Legal Business Name): KRYSTLE HAZELWOOD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/26/2026
Last Update Date: 05/26/2026
Certification Date: 05/26/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

240 S ADAMS ST
JENKS OK
74037-2573
US

IV. Provider business mailing address

240 S ADAMS ST
JENKS OK
74037-2573
US

V. Phone/Fax

Practice location:
  • Phone: 918-409-0157
  • Fax: 918-209-4788
Mailing address:
  • Phone: 918-409-0157
  • Fax: 918-209-4788

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number2770
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: