Kelly Wallace, RPT

Primary specialty

Physical TherapistTaxonomy code 225100000X

License

PT2460 Issued in OK

Practice address

13390 NE 23Rd St
Choctaw, OK 73020-8622

Phone

(405) 769-5555

Fax

(405) 769-5558

NPI assigned

Feb 5, 2006

Last updated

Apr 27, 2015By the provider in NPPES

Sex

Female

Sole proprietor

No

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 1

Addresses

Other identifiers 1

Medicare fee-for-service enrollment

Enrolled in OK

Enrollment records 1

Medicare enrollment (NPD)

Enrolled

State licenses

Practice roles

Locations

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships, National Provider Directory roles and organizations whose NPPES authorized official is this provider.

• Cutting Edge Physical Therapy PLLC

  • Physical Therapy Clinic/Center
  • Moore, OK
  • NPI 1508272006

  Physical Therapist

  Medicare reassignment NPD
• Cutting Edge Physical Therapy PLLC

  • Physical Therapy Clinic/Center
  • Yukon, OK
  • NPI 1205352028

  Physical Therapist

  NPD

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1139097600000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1430092800000",
    "number": "1184696023",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "13390 NE 23RD ST",
            "city": "CHOCTAW",
            "state": "OK",
            "postal_code": "730208622",
            "telephone_number": "405-769-5555",
            "fax_number": "405-769-5558"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "13390 NE 23RD ST",
            "city": "CHOCTAW",
            "state": "OK",
            "postal_code": "730208622",
            "telephone_number": "405-769-5555",
            "fax_number": "405-769-5558"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "WALLACE",
        "first_name": "KELLY",
        "credential": "RPT",
        "sole_proprietor": "NO",
        "sex": "F",
        "enumeration_date": "2006-02-05",
        "last_updated": "2015-04-27",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "225100000X",
            "taxonomy_group": "",
            "desc": "Physical Therapist",
            "state": "OK",
            "license": "PT2460",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "200552760A",
            "state": "OK"
        }
    ],
    "endpoints": [],
    "other_names": []
}

• Avery Alexandria Waddell
• Miranda M Wagner
• Wal-Mart Stores East LP (Walmart Pharmacy 10-4195)
• Wal-Mart Stores East, LP (Walmart Vision Center 30-4195)
• Chelsea Waldrop
• Stacie Walling
• Baylee Ward
• Hannah Ward, MFT
• Brenda Warehime
• Eileen Ruth Weides, LADC ICAADC

• Physical Therapist in Choctaw, OK
• Providers in Choctaw, OK by specialty
• Physical Therapist in Oklahoma

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Apr 27, 2015; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.