Provider Demographics
NPI:1952067340
Name:HAWORTH, KELLI ANN (PA-C)
Entity Type:Individual
Prefix:
First Name:KELLI
Middle Name:ANN
Last Name:HAWORTH
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8100 S WALKER AVE BLDG A
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73139-9475
Mailing Address - Country:US
Mailing Address - Phone:405-632-4468
Mailing Address - Fax:405-632-0436
Practice Address - Street 1:8100 S WALKER AVE BLDG A
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73139-9475
Practice Address - Country:US
Practice Address - Phone:405-632-4468
Practice Address - Fax:405-632-0436
Is Sole Proprietor?:No
Enumeration Date:2021-11-10
Last Update Date:2022-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363AM0700X, 363AS0400X
OK363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK4689OtherMEDICAL LICENSE