Provider Demographics
NPI:1457629636
Name:KELLEY, KENESHIA DAWN (MED)
Entity Type:Individual
Prefix:
First Name:KENESHIA
Middle Name:DAWN
Last Name:KELLEY
Suffix:
Gender:F
Credentials:MED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3507 E ADMIRAL PL
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74115-8211
Mailing Address - Country:US
Mailing Address - Phone:918-834-4194
Mailing Address - Fax:918-834-4189
Practice Address - Street 1:3507 E ADMIRAL PL
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74115-8211
Practice Address - Country:US
Practice Address - Phone:918-834-4194
Practice Address - Fax:918-834-4189
Is Sole Proprietor?:No
Enumeration Date:2011-12-02
Last Update Date:2011-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator