Provider Demographics
NPI:1316576085
Name:STONE, KELLY LORRAINE
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:LORRAINE
Last Name:STONE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:LORRAINE
Other - Last Name:GRIMES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1802 E 19TH ST
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74104-5403
Mailing Address - Country:US
Mailing Address - Phone:918-634-7500
Mailing Address - Fax:
Practice Address - Street 1:1802 E 19TH ST
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74104-5403
Practice Address - Country:US
Practice Address - Phone:918-634-7500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-04-05
Last Update Date:2021-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK35930390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program