Provider Demographics
NPI:1356753354
Name:TAYLOR, KELLY LYNNE
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:LYNNE
Last Name:TAYLOR
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 1:333120 E SHADY MEADOWS DR
Mailing Address - Street 2:
Mailing Address - City:WELLSTON
Mailing Address - State:OK
Mailing Address - Zip Code:74881-7101
Mailing Address - Country:US
Mailing Address - Phone:405-248-8224
Mailing Address - Fax:
Practice Address - Street 1:333120 E SHADY MEADOWS DR
Practice Address - Street 2:
Practice Address - City:WELLSTON
Practice Address - State:OK
Practice Address - Zip Code:74881-7101
Practice Address - Country:US
Practice Address - Phone:405-248-8224
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-05-24
Last Update Date:2014-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker