Provider Demographics
NPI:1790259331
Name:KLONOWSKI, KAILEY ROSE
Entity Type:Individual
Prefix:
First Name:KAILEY
Middle Name:ROSE
Last Name:KLONOWSKI
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:KAILEY
Other - Middle Name:ROSE
Other - Last Name:ERICSSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2328 N POTTENGER AVE
Mailing Address - Street 2:
Mailing Address - City:SHAWNEE
Mailing Address - State:OK
Mailing Address - Zip Code:74804-2500
Mailing Address - Country:US
Mailing Address - Phone:405-788-0193
Mailing Address - Fax:
Practice Address - Street 1:805 E ROBINSON ST
Practice Address - Street 2:
Practice Address - City:NORMAN
Practice Address - State:OK
Practice Address - Zip Code:73071-6610
Practice Address - Country:US
Practice Address - Phone:405-788-0193
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-01-16
Last Update Date:2019-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator