Provider Demographics
NPI:1205033446
Name:LUSSIER, KYLA MARIE (MD)
Entity type:Individual
Prefix:DR
First Name:KYLA
Middle Name:MARIE
Last Name:LUSSIER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:KYLA
Other - Middle Name:LUSSIER
Other - Last Name:CRITCHFIELD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 2035
Mailing Address - Street 2:
Mailing Address - City:CATOOSA
Mailing Address - State:OK
Mailing Address - Zip Code:74015-2926
Mailing Address - Country:US
Mailing Address - Phone:918-739-4885
Mailing Address - Fax:918-739-4886
Practice Address - Street 1:1755 N HIGHWAY 66
Practice Address - Street 2:SUITE F
Practice Address - City:CATOOSA
Practice Address - State:OK
Practice Address - Zip Code:74015-2409
Practice Address - Country:US
Practice Address - Phone:918-739-4885
Practice Address - Fax:918-739-4886
Is Sole Proprietor?:No
Enumeration Date:2007-06-29
Last Update Date:2012-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK258582084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200208170AMedicaid