Provider Demographics
NPI:1043580459
Name:WILEY, KELLY LYNN
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:LYNN
Last Name:WILEY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5929 N MAY AVE
Mailing Address - Street 2:STE 302 BOX 37
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73112-3909
Mailing Address - Country:US
Mailing Address - Phone:405-842-0500
Mailing Address - Fax:405-842-0505
Practice Address - Street 1:5929 N MAY AVE
Practice Address - Street 2:STE 302 BOX 37
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73112-3909
Practice Address - Country:US
Practice Address - Phone:405-842-0500
Practice Address - Fax:405-842-0505
Is Sole Proprietor?:Yes
Enumeration Date:2012-01-03
Last Update Date:2014-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200077440AMedicaid