Provider Demographics
NPI:1225057581
Name:JOY, KELLEY JEAN (DO)
Entity Type:Individual
Prefix:
First Name:KELLEY
Middle Name:JEAN
Last Name:JOY
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:110 HILLVIEW DR
Mailing Address - Street 2:
Mailing Address - City:JOPLIN
Mailing Address - State:MO
Mailing Address - Zip Code:64804-5229
Mailing Address - Country:US
Mailing Address - Phone:918-825-9900
Mailing Address - Fax:918-825-4341
Practice Address - Street 1:109 N FAIRLAND ST
Practice Address - Street 2:STE 105
Practice Address - City:PRYOR
Practice Address - State:OK
Practice Address - Zip Code:74361-4203
Practice Address - Country:US
Practice Address - Phone:918-825-9900
Practice Address - Fax:918-825-4341
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-18
Last Update Date:2019-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO115577207Q00000X, 204D00000X
OK3926207Q00000X, 204D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes204D00000XAllopathic & Osteopathic PhysiciansNeuromusculoskeletal Medicine & OMM
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK030474832OtherTAX ID #
OK100195450BMedicaid
OKH67447Medicare UPIN
OK100195450BMedicaid