Healthcare Provider Details

I. General information

NPI: 1285021501
Provider Name (Legal Business Name): SALLY HOLT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: SALLY ANN WALLACE

II. Dates (important events)

Enumeration Date: 04/24/2015
Last Update Date: 12/18/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

215 W LINN ST
NORMAN OK
73069-5837
US

IV. Provider business mailing address

929 BLUE BIRD TER
PURCELL OK
73080-3041
US

V. Phone/Fax

Practice location:
  • Phone: 405-321-0022
  • Fax:
Mailing address:
  • Phone: 405-574-4477
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: