Provider Demographics
NPI:1972174324
Name:BURGESS, KELSEY ANN
Entity Type:Individual
Prefix:
First Name:KELSEY
Middle Name:ANN
Last Name:BURGESS
Suffix:
Gender:F
Credentials:
Other - Prefix:MRS
Other - First Name:KELSEY
Other - Middle Name:ANN
Other - Last Name:BURGESS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:110 N 4TH ST
Mailing Address - Street 2:
Mailing Address - City:PONCA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:74601-4527
Mailing Address - Country:US
Mailing Address - Phone:580-749-5056
Mailing Address - Fax:
Practice Address - Street 1:407 W SOUTH AVE
Practice Address - Street 2:
Practice Address - City:PONCA CITY
Practice Address - State:OK
Practice Address - Zip Code:74601-6133
Practice Address - Country:US
Practice Address - Phone:580-749-5056
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-07-07
Last Update Date:2023-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator