Provider Demographics
NPI:1700383981
Name:WOODRAL, KELLY RENEE
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:RENEE
Last Name:WOODRAL
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 1:200 HIGHWAY 128 APT 39
Mailing Address - Street 2:
Mailing Address - City:HEAVENER
Mailing Address - State:OK
Mailing Address - Zip Code:74937-7467
Mailing Address - Country:US
Mailing Address - Phone:918-839-0113
Mailing Address - Fax:
Practice Address - Street 1:200 HIGHWAY 128 APT 39
Practice Address - Street 2:
Practice Address - City:HEAVENER
Practice Address - State:OK
Practice Address - Zip Code:74937-7467
Practice Address - Country:US
Practice Address - Phone:918-839-0113
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-04-12
Last Update Date:2018-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator