Provider Demographics
NPI:1053080556
Name:HEARN, KELLY ANN
Entity Type:Individual
Prefix:MS
First Name:KELLY
Middle Name:ANN
Last Name:HEARN
Suffix:
Gender:F
Credentials:
Other - Prefix:DR
Other - First Name:MARY
Other - Middle Name:E
Other - Last Name:GATES
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PHD
Mailing Address - Street 1:PO BOX 695
Mailing Address - Street 2:
Mailing Address - City:CHOCTAW
Mailing Address - State:OK
Mailing Address - Zip Code:73020-0695
Mailing Address - Country:US
Mailing Address - Phone:405-390-8131
Mailing Address - Fax:405-835-2253
Practice Address - Street 1:14625 NE 23RD ST
Practice Address - Street 2:
Practice Address - City:CHOCTAW
Practice Address - State:OK
Practice Address - Zip Code:73020-8728
Practice Address - Country:US
Practice Address - Phone:405-390-8131
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-09-08
Last Update Date:2021-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist