Provider Demographics
NPI:1598039695
Name:CANADY, KAYLYNNE NICOLE
Entity Type:Individual
Prefix:
First Name:KAYLYNNE
Middle Name:NICOLE
Last Name:CANADY
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:PO BOX 681
Mailing Address - Street 2:
Mailing Address - City:STILLWATER
Mailing Address - State:OK
Mailing Address - Zip Code:74076-0681
Mailing Address - Country:US
Mailing Address - Phone:580-336-8686
Mailing Address - Fax:
Practice Address - Street 1:9600 W 6TH AVE
Practice Address - Street 2:
Practice Address - City:STILLWATER
Practice Address - State:OK
Practice Address - Zip Code:74074-1017
Practice Address - Country:US
Practice Address - Phone:580-336-8686
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-03-07
Last Update Date:2012-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225C00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Counselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK22Medicaid