Basic Information
| Provider Information | |||||||||
| NPI: | 1174189914 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SHANNON | ||||||||
| FirstName: | KYLIE | ||||||||
| MiddleName: | BETH | ||||||||
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| Credential: | DPT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2488 E 81ST ST STE 290 | ||||||||
| Address2: | |||||||||
| City: | TULSA | ||||||||
| State: | OK | ||||||||
| PostalCode: | 741374265 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9189273226 | ||||||||
| FaxNumber: | 9189273193 | ||||||||
| Practice Location | |||||||||
| Address1: | 13720 E 86TH ST N STE 140 | ||||||||
| Address2: | |||||||||
| City: | OWASSO | ||||||||
| State: | OK | ||||||||
| PostalCode: | 740558738 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9186098088 | ||||||||
| FaxNumber: | 9186098089 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/16/2019 | ||||||||
| LastUpdateDate: | 09/30/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/30/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 5659 | OK | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 200841600A | 05 | OK | MEDICAID |