Provider Demographics
NPI:1033764360
Name:LANDON, KELSEY DANIELLE (PA-C)
Entity Type:Individual
Prefix:
First Name:KELSEY
Middle Name:DANIELLE
Last Name:LANDON
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1205 CREEKDALE
Mailing Address - Street 2:
Mailing Address - City:ENID
Mailing Address - State:OK
Mailing Address - Zip Code:73703-2818
Mailing Address - Country:US
Mailing Address - Phone:580-583-7505
Mailing Address - Fax:
Practice Address - Street 1:825 E OWEN K GARRIOTT RD
Practice Address - Street 2:
Practice Address - City:ENID
Practice Address - State:OK
Practice Address - Zip Code:73701-5928
Practice Address - Country:US
Practice Address - Phone:405-844-4978
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-08-04
Last Update Date:2019-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK3058363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant