Basic Information
| Provider Information | |||||||||
| NPI: | 1700033867 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ROLLINS | ||||||||
| FirstName: | KELLI | ||||||||
| MiddleName: | ANN | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | ARNP | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | COOK | ||||||||
| OtherFirstName: | KELLI | ||||||||
| OtherMiddleName: | ANN | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 7800 NW 85TH TER STE 200 | ||||||||
| Address2: | |||||||||
| City: | OKLAHOMA CITY | ||||||||
| State: | OK | ||||||||
| PostalCode: | 731323385 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4059727239 | ||||||||
| FaxNumber: | 4057531863 | ||||||||
| Practice Location | |||||||||
| Address1: | 2403 W WRANGLER BLVD STE A | ||||||||
| Address2: | |||||||||
| City: | SEMINOLE | ||||||||
| State: | OK | ||||||||
| PostalCode: | 748681900 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4053824939 | ||||||||
| FaxNumber: | 4053824940 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/20/2008 | ||||||||
| LastUpdateDate: | 02/22/2017 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 86110 | OK | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | R0086110 | 01 | OK | LICENSE | OTHER |