Provider Demographics
NPI:1699382655
Name:PRIDEMORE, KELLI RENEE (PTA)
Entity type:Individual
Prefix:
First Name:KELLI
Middle Name:RENEE
Last Name:PRIDEMORE
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 1:419 S 276TH EAST AVE
Mailing Address - Street 2:
Mailing Address - City:CATOOSA
Mailing Address - State:OK
Mailing Address - Zip Code:74015-5535
Mailing Address - Country:US
Mailing Address - Phone:918-899-8391
Mailing Address - Fax:
Practice Address - Street 1:3701 M.L.K. JR BLVD
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74106
Practice Address - Country:US
Practice Address - Phone:918-425-3583
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-24
Last Update Date:2025-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy AssistantGroup - Single Specialty