Basic Information
| Provider Information | |||||||||
| NPI: | 1588113831 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | STEPHENS | ||||||||
| FirstName: | KELLY | ||||||||
| MiddleName: | |||||||||
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| Credential: | PMHNP-BC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 521147 | ||||||||
| Address2: | |||||||||
| City: | TULSA | ||||||||
| State: | OK | ||||||||
| PostalCode: | 741521147 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9186080380 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1402 N FLORENCE AVE STE B | ||||||||
| Address2: | |||||||||
| City: | CLAREMORE | ||||||||
| State: | OK | ||||||||
| PostalCode: | 740173159 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9186080380 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/28/2016 | ||||||||
| LastUpdateDate: | 03/06/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 03/06/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LP0808X | R0060065 | OK | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Psych/Mental Health |
No ID Information.