Provider Demographics
NPI:1053034843
Name:CORDELL, MISTY (CMT)
Entity type:Individual
Prefix:
First Name:MISTY
Middle Name:
Last Name:CORDELL
Suffix:
Gender:F
Credentials:CMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2103 S MAIN ST STE N
Mailing Address - Street 2:
Mailing Address - City:ELK CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73644-9167
Mailing Address - Country:US
Mailing Address - Phone:580-243-0700
Mailing Address - Fax:
Practice Address - Street 1:2103 S MAIN ST STE N
Practice Address - Street 2:
Practice Address - City:ELK CITY
Practice Address - State:OK
Practice Address - Zip Code:73644-9167
Practice Address - Country:US
Practice Address - Phone:580-243-0700
Practice Address - Fax:580-243-0770
Is Sole Proprietor?:No
Enumeration Date:2022-09-26
Last Update Date:2022-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK105918225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist