Provider Demographics
NPI:1497402366
Name:CHILDRESS, KYLER
Entity Type:Individual
Prefix:
First Name:KYLER
Middle Name:
Last Name:CHILDRESS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1803SOUTH WOOD DR
Mailing Address - Street 2:
Mailing Address - City:OKMUKGEE
Mailing Address - State:OK
Mailing Address - Zip Code:74447
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1893 SOUTH WOOD DR
Practice Address - Street 2:
Practice Address - City:OKMULGEE
Practice Address - State:OK
Practice Address - Zip Code:74447
Practice Address - Country:US
Practice Address - Phone:918-282-6444
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-03-09
Last Update Date:2022-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist