Provider Demographics
NPI:1538893029
Name:WIARD, KRISTIN J
Entity type:Individual
Prefix:
First Name:KRISTIN
Middle Name:J
Last Name:WIARD
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18617 E 46TH PL S
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74134-5501
Mailing Address - Country:US
Mailing Address - Phone:918-946-7100
Mailing Address - Fax:
Practice Address - Street 1:711 N 5TH ST
Practice Address - Street 2:
Practice Address - City:JENKS
Practice Address - State:OK
Practice Address - Zip Code:74037-3343
Practice Address - Country:US
Practice Address - Phone:918-299-8508
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-07-12
Last Update Date:2022-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK1304224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant