=====================================================
General NPI Number Information
=====================================================
NPI Number | 1609716877
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | BRYLEE RUSSELL PTA
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/30/2026
-----------------------------------------------------
Last Update Date | 03/30/2026
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 201 W MAIN ST. SERENE PELVIC PHYSICAL THERAPY SUITE 4
-----------------------------------------------------
City | TUTTLE
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 73089
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 405-463-4634
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 460 N PEBBLE CREEK TERRANCE APT 302
-----------------------------------------------------
City | MUSTANG
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 73064
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225200000X
-----------------------------------------------------
Taxonomy Name | Physical Therapy Assistant
-----------------------------------------------------
License Number | 4022
-----------------------------------------------------
License Number State | OK
-----------------------------------------------------