Provider Demographics
NPI:1134952419
Name:YOUNG, KEYANNDRA NICHELLE
Entity type:Individual
Prefix:
First Name:KEYANNDRA
Middle Name:NICHELLE
Last Name:YOUNG
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 1:700 NE 122ND ST APT 1101
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73114-8149
Mailing Address - Country:US
Mailing Address - Phone:580-741-0314
Mailing Address - Fax:
Practice Address - Street 1:700 NE 122ND ST APT 1101
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73114-8149
Practice Address - Country:US
Practice Address - Phone:580-741-0314
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-08-22
Last Update Date:2024-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK219906363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health