Provider Demographics
NPI:1619569852
Name:SWAN, KELLY MARIE (PTA)
Entity type:Individual
Prefix:MRS
First Name:KELLY
Middle Name:MARIE
Last Name:SWAN
Suffix:
Gender:
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19822 S COVEY CT
Mailing Address - Street 2:
Mailing Address - City:CLAREMORE
Mailing Address - State:OK
Mailing Address - Zip Code:74019-0041
Mailing Address - Country:US
Mailing Address - Phone:918-274-1300
Mailing Address - Fax:
Practice Address - Street 1:12912 E 86TH ST N
Practice Address - Street 2:
Practice Address - City:OWASSO
Practice Address - State:OK
Practice Address - Zip Code:74055-8608
Practice Address - Country:US
Practice Address - Phone:918-524-3833
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-02-09
Last Update Date:2025-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK4607224822081S0010X
OK1353208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
No2081S0010XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationSports Medicine