Provider Demographics
NPI:1841416443
Name:GILLINGHAM, KELLY KAEMPER (OTR)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:KAEMPER
Last Name:GILLINGHAM
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:SHARON
Other - Last Name:GILLINGHAM
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:OTR
Mailing Address - Street 1:RR 1 BOX 57
Mailing Address - Street 2:
Mailing Address - City:BINGER
Mailing Address - State:OK
Mailing Address - Zip Code:73009-9731
Mailing Address - Country:US
Mailing Address - Phone:405-643-2577
Mailing Address - Fax:405-643-2577
Practice Address - Street 1:801 N WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:WEATHERFORD
Practice Address - State:OK
Practice Address - Zip Code:73096-4032
Practice Address - Country:US
Practice Address - Phone:580-772-3993
Practice Address - Fax:580-774-1032
Is Sole Proprietor?:No
Enumeration Date:2007-04-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK967225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist