Provider Demographics
NPI:1790182368
Name:SPYCHALSKI, KELLY (NP)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:SPYCHALSKI
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:LEIGH
Other - Last Name:PETERSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:430 N MONTE VISTA ST
Mailing Address - Street 2:
Mailing Address - City:ADA
Mailing Address - State:OK
Mailing Address - Zip Code:74820-4610
Mailing Address - Country:US
Mailing Address - Phone:580-421-1141
Mailing Address - Fax:580-421-1124
Practice Address - Street 1:430 N MONTE VISTA ST
Practice Address - Street 2:
Practice Address - City:ADA
Practice Address - State:OK
Practice Address - Zip Code:74820-4610
Practice Address - Country:US
Practice Address - Phone:580-421-1141
Practice Address - Fax:580-421-1124
Is Sole Proprietor?:No
Enumeration Date:2014-11-26
Last Update Date:2023-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH16847363LA2200X
OK214685363LG0600X
WY38354.1542363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology