| Doctor Name: | KELLY WALLACE |
| NPI Number: | 1184696023 |
| Entity Type Code: | Individual (1) |
| Gender: | F |
| Credentials: | RPT |
| License Number: | PT2460 |
| Business Practice Address: | 13390 Ne 23rd St Choctaw, OK - 730208622 |
| Business Phone Number: | 4057695555 |
| Business Fax Number: | 4057695558 |
| Mailing Address: | 13390 Ne 23rd St, CHOCTAW |
| State: | OK |
| Postal Code: | 730208622 |
| Phone Number: | 4057695555 |
| Fax Number: | 4057695558 |
| NPI Enumeration Date: | 02/05/2006 |
| NPI Last Update Date: | 04/27/2015 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 225100000X |
| License Number: | PT2460 |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | OK |
| Taxonomy Type: | Respiratory, Developmental, Rehabilitative and Restorative Service Providers |
| Taxonomy Classification: | Physical Therapist |
| Taxonomy Specialization: | |
| Taxonomy Definition: | (1) Physical therapists are health care professionals who evaluate and treat people with health problems resulting from injury or disease. PT |