Basic Information
| Provider Information | |||||||||
| NPI: | 1801431846 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KELLY | ||||||||
| FirstName: | KAYLA | ||||||||
| MiddleName: | ANNE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2705 SW 97TH CT | ||||||||
| Address2: | |||||||||
| City: | OKLAHOMA CITY | ||||||||
| State: | OK | ||||||||
| PostalCode: | 731597320 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4052077075 | ||||||||
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| Practice Location | |||||||||
| Address1: | 202 S WASHITA AVE | ||||||||
| Address2: | |||||||||
| City: | WYNNEWOOD | ||||||||
| State: | OK | ||||||||
| PostalCode: | 730987820 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4056654385 | ||||||||
| FaxNumber: | 4056656396 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/13/2019 | ||||||||
| LastUpdateDate: | 11/13/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 171M00000X | OK | Y | Other Service Providers | Case Manager/Care Coordinator |
No ID Information.