Provider Demographics
NPI:1518478890
Name:GREGORY, KELLIE DIANE
Entity Type:Individual
Prefix:
First Name:KELLIE
Middle Name:DIANE
Last Name:GREGORY
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 1:13413 N 91ST EAST AVE
Mailing Address - Street 2:
Mailing Address - City:COLLINSVILLE
Mailing Address - State:OK
Mailing Address - Zip Code:74021-3969
Mailing Address - Country:US
Mailing Address - Phone:918-955-5062
Mailing Address - Fax:
Practice Address - Street 1:13413 N 91ST EAST AVE
Practice Address - Street 2:
Practice Address - City:COLLINSVILLE
Practice Address - State:OK
Practice Address - Zip Code:74021-3969
Practice Address - Country:US
Practice Address - Phone:918-955-5062
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-10-13
Last Update Date:2017-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist