Provider Demographics
NPI:1376526756
Name:WALWORTH, KELLY J (PAC)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:J
Last Name:WALWORTH
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:DEPT 96-0317
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73196-0317
Mailing Address - Country:US
Mailing Address - Phone:405-521-1969
Mailing Address - Fax:405-521-1979
Practice Address - Street 1:13174 N MACARTHUR BLVD
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73142-3017
Practice Address - Country:US
Practice Address - Phone:405-721-5555
Practice Address - Fax:405-470-7093
Is Sole Proprietor?:No
Enumeration Date:2005-11-21
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
OK1460363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK1710198569OtherGROUP NPI
OK200265130AMedicaid
OK1710198569OtherGROUP NPI