Basic Information
Provider Information
NPI: 1700494507
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: OLTMANNS
FirstName: CARLY
MiddleName:  
NamePrefix:  
NameSuffix:  
Credential: PT
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 440 MERCHANT DR
Address2:  
City: NORMAN
State: OK
PostalCode: 730696470
CountryCode: US
TelephoneNumber: 4058098713
FaxNumber:  
Practice Location
Address1: 108 W HARRISON AVE
Address2:  
City: GUTHRIE
State: OK
PostalCode: 730444727
CountryCode: US
TelephoneNumber: 4052939892
FaxNumber:  
Other Information
ProviderEnumerationDate: 07/17/2020
LastUpdateDate: 05/13/2022
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: F
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: N
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate: 05/13/2022

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
225100000X5884OKY Respiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist 

ID Information
IDTypeStateIssuerDescription
200922880A05OK MEDICAID


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