Provider Demographics
NPI:1922350982
Name:KELLEY, LANA C (HAD)
Entity Type:Individual
Prefix:
First Name:LANA
Middle Name:C
Last Name:KELLEY
Suffix:
Gender:F
Credentials:HAD
Other - Prefix:
Other - First Name:LANA
Other - Middle Name:
Other - Last Name:MOSES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3385 ROY ORR BLVD
Mailing Address - Street 2:
Mailing Address - City:GRAND PRAIRIE
Mailing Address - State:TX
Mailing Address - Zip Code:75050-4208
Mailing Address - Country:US
Mailing Address - Phone:469-426-6049
Mailing Address - Fax:
Practice Address - Street 1:12905 E 96TH ST N
Practice Address - Street 2:
Practice Address - City:OWASSO
Practice Address - State:OK
Practice Address - Zip Code:74055-4719
Practice Address - Country:US
Practice Address - Phone:918-928-2880
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-10-15
Last Update Date:2020-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK930237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist