Provider Demographics
NPI:1184966004
Name:TODD, KELLY JEAN (ATC)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:JEAN
Last Name:TODD
Suffix:
Gender:F
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5022 S TOLEDO #19M
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74135
Mailing Address - Country:US
Mailing Address - Phone:918-869-9759
Mailing Address - Fax:
Practice Address - Street 1:3027 S NEW HAVEN AVE
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74114-6131
Practice Address - Country:US
Practice Address - Phone:918-869-9759
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-03-18
Last Update Date:2013-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK336172255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer