Provider Demographics
NPI:1215302799
Name:HERRON, CHRISTINE (PTA)
Entity type:Individual
Prefix:
First Name:CHRISTINE
Middle Name:
Last Name:HERRON
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 ORDNANCE WAY
Mailing Address - Street 2:
Mailing Address - City:MCALESTER
Mailing Address - State:OK
Mailing Address - Zip Code:74501
Mailing Address - Country:US
Mailing Address - Phone:757-291-5276
Mailing Address - Fax:
Practice Address - Street 1:1029 E. WASHINGTON AVE
Practice Address - Street 2:
Practice Address - City:MCALESTER
Practice Address - State:OK
Practice Address - Zip Code:74501
Practice Address - Country:US
Practice Address - Phone:918-423-2220
Practice Address - Fax:918-423-2620
Is Sole Proprietor?:No
Enumeration Date:2015-12-09
Last Update Date:2015-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK2593225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant