MEDICARE: MRS. CARENZA ANGELINE SHIELDS PTA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225200000X	Physical Therapy Assistant	1071	OK

General Provider Information

NPI Number	:	1679799746
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. CARENZA ANGELINE SHIELDS PTA

Provider Business Mailing Address
First Line	:	2011 W 119TH ST S
Second Line	:
City	:	JENKS
State	:	OK
Zip	:	74037-4380
Country	:	US
Telephone Number	:	405-613-5504
Fax Number	:

Provider Business Practice Location Address
First Line	:	3030 NW EXPRESSWAY ST STE 809
Second Line	:
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73112-5466
Country	:	US
Telephone Number	:	405-917-7160
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/17/2007
Last Update Date	:	07/08/2007

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