Provider Demographics
NPI:1346501202
Name:DAVIS, KELLY LYNN
Entity Type:Individual
Prefix:MRS
First Name:KELLY
Middle Name:LYNN
Last Name:DAVIS
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 1:18247 W RUNNING SPRINGS RD
Mailing Address - Street 2:
Mailing Address - City:PARK HILL
Mailing Address - State:OK
Mailing Address - Zip Code:74451-2017
Mailing Address - Country:US
Mailing Address - Phone:918-441-6337
Mailing Address - Fax:
Practice Address - Street 1:18247 W RUNNING SPRINGS RD
Practice Address - Street 2:
Practice Address - City:PARK HILL
Practice Address - State:OK
Practice Address - Zip Code:74451-2017
Practice Address - Country:US
Practice Address - Phone:918-441-6337
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-06
Last Update Date:2012-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
No171W00000XOther Service ProvidersContractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200305190BMedicaid