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General NPI Number Information
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NPI Number | 1619569852
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Entity Type | Individual
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Provider Name | KELLY MARIE SWAN PTA
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Gender | Female
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Dates
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Enumeration Date | 02/09/2021
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Last Update Date | 05/09/2025
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Provider Practice Location Address
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Address Line | 12912 E 86TH ST N
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City | OWASSO
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State | OK
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Zip | 74055-8608
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Country | US
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Telephone | 918-524-3833
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Fax |
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Provider Business Mailing Address
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Address Line | 19822 S COVEY CT
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City | CLAREMORE
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State | OK
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Zip | 74019-0041
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Country | US
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Telephone | 918-274-1300
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2081S0010X
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Taxonomy Name | Sports Medicine (Physical Medicine & Rehabilitation) Physician
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License Number | 460722482
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License Number State | OK
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Taxonomy #2
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Taxonomy Code | 208100000X
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Taxonomy Name | Physical Medicine & Rehabilitation Physician
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License Number | 1353
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License Number State | OK
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