Provider Demographics
NPI:1114917705
Name:ROLLINS, KAYLY ELIZABETH (MS)
Entity Type:Individual
Prefix:
First Name:KAYLY
Middle Name:ELIZABETH
Last Name:ROLLINS
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:150 DEER CREEK RD
Mailing Address - Street 2:
Mailing Address - City:EDMOND
Mailing Address - State:OK
Mailing Address - Zip Code:73012-9317
Mailing Address - Country:US
Mailing Address - Phone:405-760-9686
Mailing Address - Fax:
Practice Address - Street 1:150 DEER CREEK RD
Practice Address - Street 2:
Practice Address - City:EDMOND
Practice Address - State:OK
Practice Address - Zip Code:73012-9317
Practice Address - Country:US
Practice Address - Phone:405-760-9686
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-25
Last Update Date:2012-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK2652235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100666260AMedicaid
OK736017987112OtherDEPT OF REHAB