Healthcare Provider Details

I. General information

NPI: 1427647528
Provider Name (Legal Business Name): KELLY JO WILLIAMS PTA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: KELLY JO MARKWARDT PTA

II. Dates (important events)

Enumeration Date: 01/13/2021
Last Update Date: 01/13/2021
Certification Date: 01/13/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6715 E 41ST ST
TULSA OK
74145-4520
US

IV. Provider business mailing address

3422 S 76TH WEST AVE
TULSA OK
74107-4538
US

V. Phone/Fax

Practice location:
  • Phone: 918-806-0106
  • Fax:
Mailing address:
  • Phone: 918-850-7295
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number2614
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: