Provider Demographics
NPI:1386004380
Name:SKY-EAGLE, KELLEY FROST (MS RD LD CDE)
Entity Type:Individual
Prefix:
First Name:KELLEY
Middle Name:FROST
Last Name:SKY-EAGLE
Suffix:
Gender:F
Credentials:MS RD LD CDE
Other - Prefix:
Other - First Name:KELLEY
Other - Middle Name:MICHELLE
Other - Last Name:FROST
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1122 NE 13TH ST # 262
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73117-1039
Mailing Address - Country:US
Mailing Address - Phone:405-271-5400
Mailing Address - Fax:405-271-1127
Practice Address - Street 1:1200 CHILDRENS AVE STE 4D
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73104-4637
Practice Address - Country:US
Practice Address - Phone:405-271-5400
Practice Address - Fax:405-271-1127
Is Sole Proprietor?:No
Enumeration Date:2016-03-03
Last Update Date:2023-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
1043935133V00000X
OKLD2123133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered