Healthcare Provider Details

I. General information

NPI: 1407012115
Provider Name (Legal Business Name): AUTUMN NICOLE ANESHANSLEY MPT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/01/2008
Last Update Date: 06/11/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3838 50TH ST
LUBBOCK TX
79413-3808
US

IV. Provider business mailing address

3732 S LOUISVILLE AVE
TULSA OK
74135-2244
US

V. Phone/Fax

Practice location:
  • Phone: 806-792-5522
  • Fax: 806-785-7582
Mailing address:
  • Phone: 580-302-0571
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number4099
License Number StateOK
# 2
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number1225532
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: