Healthcare Provider Details

I. General information

NPI: 1679104780
Provider Name (Legal Business Name): ASHLEY CHEYENNE SEVILLA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/28/2020
Last Update Date: 08/07/2025
Certification Date: 08/07/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 S BLISS AVE
TAHLEQUAH OK
74464-2512
US

IV. Provider business mailing address

1400 HICKORY HILLS DR
FORT GIBSON OK
74434-6387
US

V. Phone/Fax

Practice location:
  • Phone: 918-458-3100
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number2987
License Number StateOK
# 2
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number6591
License Number StateOK

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: