Provider Demographics
NPI:1871878868
Name:FENTRESS, BEVERLY K. (RPT)
Entity type:Individual
Prefix:MRS
First Name:BEVERLY K.
Middle Name:
Last Name:FENTRESS
Suffix:
Gender:F
Credentials:RPT
Other - Prefix:MISS
Other - First Name:BEVERLY K.
Other - Middle Name:
Other - Last Name:DICKEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RPT
Mailing Address - Street 1:6112 WINCHESTER DR
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73162-1719
Mailing Address - Country:US
Mailing Address - Phone:405-621-9378
Mailing Address - Fax:
Practice Address - Street 1:6112 WINCHESTER DR
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73162-1719
Practice Address - Country:US
Practice Address - Phone:405-621-9378
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-10-21
Last Update Date:2011-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK6872251P0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatrics