Provider Demographics
NPI:1821376138
Name:VANTUYL, KELLIE DAWN (DO)
Entity Type:Individual
Prefix:DR
First Name:KELLIE
Middle Name:DAWN
Last Name:VANTUYL
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:6600 S YALE AVE
Mailing Address - Street 2:SUITE 1400
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74136-3347
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:30011 E STATE HIGHWAY 51
Practice Address - Street 2:
Practice Address - City:COWETA
Practice Address - State:OK
Practice Address - Zip Code:74429-7681
Practice Address - Country:US
Practice Address - Phone:918-486-2161
Practice Address - Fax:918-486-3135
Is Sole Proprietor?:No
Enumeration Date:2011-08-03
Last Update Date:2024-03-20
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
OK5137207Q00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200401090AMedicaid