Basic Information
| Provider Information | |||||||||
| NPI: | 1306448113 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KELLEY | ||||||||
| FirstName: | KAELLA | ||||||||
| MiddleName: | R | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2225 N UNION ST. | ||||||||
| Address2: | |||||||||
| City: | PONCA CITY | ||||||||
| State: | OK | ||||||||
| PostalCode: | 746011536 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5803085515 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 2225 N UNION ST. | ||||||||
| Address2: | |||||||||
| City: | PONCA CITY | ||||||||
| State: | OK | ||||||||
| PostalCode: | 746011536 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5803085515 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/16/2020 | ||||||||
| LastUpdateDate: | 01/22/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 01/22/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 175T00000X | N084074652 | OK | Y |
No ID Information.