1174189914 NPI number — KYLIE BETH SHANNON DPT

Table of content: KYLIE BETH SHANNON DPT (NPI 1174189914)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1174189914 NPI number — KYLIE BETH SHANNON DPT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SHANNON
Provider First Name:
KYLIE
Provider Middle Name:
BETH
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
DPT
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1174189914
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/30/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2488 E 81ST ST STE 290
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
TULSA
Provider Business Mailing Address State Name:
OK
Provider Business Mailing Address Postal Code:
74137-4265
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
918-927-3226
Provider Business Mailing Address Fax Number:
918-927-3193

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
13720 E 86TH ST N STE 140
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
OWASSO
Provider Business Practice Location Address State Name:
OK
Provider Business Practice Location Address Postal Code:
74055-8738
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
918-609-8088
Provider Business Practice Location Address Fax Number:
918-609-8089
Provider Enumeration Date:
05/16/2019

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 225100000X , with the licence number:  5659 , registered in the state of OK ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 200841600A , issued by the state of ( OK ) . This identifiers is of the category "MEDICAID".




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