Provider Demographics
NPI:1164085502
Name:KELLEY, AMMIE WALL
Entity Type:Individual
Prefix:
First Name:AMMIE
Middle Name:WALL
Last Name:KELLEY
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 1:1245 S UTICA AVE STE 100
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74104-4214
Mailing Address - Country:US
Mailing Address - Phone:918-579-3850
Mailing Address - Fax:918-579-3859
Practice Address - Street 1:1245 S UTICA AVE STE 100
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74104-4214
Practice Address - Country:US
Practice Address - Phone:918-579-3850
Practice Address - Fax:918-579-3859
Is Sole Proprietor?:No
Enumeration Date:2019-04-22
Last Update Date:2019-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK102373363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner