Provider Demographics
NPI:1265019863
Name:HARRIS, KELLEY MARIE (DO)
Entity Type:Individual
Prefix:
First Name:KELLEY
Middle Name:MARIE
Last Name:HARRIS
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 1:307 AUTUMNWOOD DR
Mailing Address - Street 2:
Mailing Address - City:RUSSELLVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72802-7972
Mailing Address - Country:US
Mailing Address - Phone:479-651-1685
Mailing Address - Fax:
Practice Address - Street 1:744 W 9TH ST
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74127-9907
Practice Address - Country:US
Practice Address - Phone:918-599-1000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-03-28
Last Update Date:2023-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
OK1265019863208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program