Provider Demographics
NPI:1922385392
Name:KELLY, ALICE BAYLES (DPH)
Entity Type:Individual
Prefix:DR
First Name:ALICE
Middle Name:BAYLES
Last Name:KELLY
Suffix:
Gender:F
Credentials:DPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2300 N 14TH ST
Mailing Address - Street 2:
Mailing Address - City:PONCA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:74601-1729
Mailing Address - Country:US
Mailing Address - Phone:580-767-1584
Mailing Address - Fax:580-767-1083
Practice Address - Street 1:2300 N 14TH ST
Practice Address - Street 2:
Practice Address - City:PONCA CITY
Practice Address - State:OK
Practice Address - Zip Code:74601-1729
Practice Address - Country:US
Practice Address - Phone:580-767-1584
Practice Address - Fax:580-767-1083
Is Sole Proprietor?:Yes
Enumeration Date:2011-11-13
Last Update Date:2011-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK9605183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist