Provider Demographics
NPI:1285830158
Name:STALLARD, KRISTOPHER RYAN (CM-II)
Entity Type:Individual
Prefix:
First Name:KRISTOPHER
Middle Name:RYAN
Last Name:STALLARD
Suffix:
Gender:M
Credentials:CM-II
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1611 S UTICA AVE
Mailing Address - Street 2:PMB 142
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74104
Mailing Address - Country:US
Mailing Address - Phone:918-378-9310
Mailing Address - Fax:918-921-3299
Practice Address - Street 1:1055 S HOUSTON AVE
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74127-9043
Practice Address - Country:US
Practice Address - Phone:918-921-3200
Practice Address - Fax:918-921-3299
Is Sole Proprietor?:No
Enumeration Date:2007-06-26
Last Update Date:2016-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK300858171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator