Healthcare Provider Details

I. General information

NPI: 1619569852
Provider Name (Legal Business Name): KELLY MARIE SWAN PTA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/09/2021
Last Update Date: 05/09/2025
Certification Date: 04/30/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12912 E 86TH ST N
OWASSO OK
74055-8608
US

IV. Provider business mailing address

19822 S COVEY CT
CLAREMORE OK
74019-0041
US

V. Phone/Fax

Practice location:
  • Phone: 918-524-3833
  • Fax:
Mailing address:
  • Phone: 918-274-1300
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2081S0010X
TaxonomySports Medicine (Physical Medicine & Rehabilitation) Physician
License Number460722482
License Number StateOK
# 2
Primary TaxonomyY
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number1353
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: