Healthcare Provider Details

I. General information

NPI: 1659738136
Provider Name (Legal Business Name): COURTNEY ANNE PUTNAM ATC, LAT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/28/2016
Last Update Date: 01/28/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2625 S CAMBRIDGE DR
STILLWATER OK
74074-2246
US

IV. Provider business mailing address

2625 S CAMBRIDGE DR
STILLWATER OK
74074-2246
US

V. Phone/Fax

Practice location:
  • Phone: 405-880-3482
  • Fax:
Mailing address:
  • Phone: 405-880-3482
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number657
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: