Provider Demographics
NPI:1730386756
Name:WADDLE, SHELLY RANAE (OTA)
Entity type:Individual
Prefix:
First Name:SHELLY
Middle Name:RANAE
Last Name:WADDLE
Suffix:
Gender:F
Credentials:OTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1013 S.W. 128 ST
Mailing Address - Street 2:
Mailing Address - City:OKC
Mailing Address - State:OK
Mailing Address - Zip Code:73170
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1013 SW 128TH ST
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73170-6951
Practice Address - Country:US
Practice Address - Phone:405-691-3418
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-07-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK473224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant