Provider Demographics
NPI:1992201487
Name:POLLARD, KAITLYN MACKENZI
Entity Type:Individual
Prefix:
First Name:KAITLYN
Middle Name:MACKENZI
Last Name:POLLARD
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:326 BOGGY CREEK DR
Mailing Address - Street 2:
Mailing Address - City:ARDMORE
Mailing Address - State:OK
Mailing Address - Zip Code:73401-6698
Mailing Address - Country:US
Mailing Address - Phone:580-798-4523
Mailing Address - Fax:580-319-5349
Practice Address - Street 1:326 BOGGY CREEK DR
Practice Address - Street 2:
Practice Address - City:ARDMORE
Practice Address - State:OK
Practice Address - Zip Code:73401-6698
Practice Address - Country:US
Practice Address - Phone:580-798-4523
Practice Address - Fax:580-319-5349
Is Sole Proprietor?:No
Enumeration Date:2018-04-03
Last Update Date:2018-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKK083636788156F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156F00000XEye and Vision Services ProvidersTechnician/Technologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OKK083636788OtherDRIVERS LICENSE