Basic Information
| Provider Information | |||||||||
| NPI: | 1194061143 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HUMPHREYS | ||||||||
| FirstName: | KALLIE | ||||||||
| MiddleName: | BLYTHE | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 269032 | ||||||||
| Address2: | |||||||||
| City: | OKLAHOMA CITY | ||||||||
| State: | OK | ||||||||
| PostalCode: | 731269032 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4059512545 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 3300 NW EXPRESSWAY | ||||||||
| Address2: | |||||||||
| City: | OKLAHOMA CITY | ||||||||
| State: | OK | ||||||||
| PostalCode: | 731124999 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4059493011 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/19/2012 | ||||||||
| LastUpdateDate: | 06/08/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/08/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AM0700X | APA2188 | OK | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical | 363A00000X | 2188 | OK | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.