Provider Demographics
NPI:1881080018
Name:O'BRYANT, KILI GRACE
Entity type:Individual
Prefix:
First Name:KILI
Middle Name:GRACE
Last Name:O'BRYANT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:KILI
Other - Middle Name:GRACE
Other - Last Name:WETHERELL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 2454
Mailing Address - Street 2:
Mailing Address - City:PALMER
Mailing Address - State:AK
Mailing Address - Zip Code:99645-2454
Mailing Address - Country:US
Mailing Address - Phone:541-980-3294
Mailing Address - Fax:888-497-1565
Practice Address - Street 1:2500 S WOODWORTH LOOP
Practice Address - Street 2:
Practice Address - City:PALMER
Practice Address - State:AK
Practice Address - Zip Code:99645
Practice Address - Country:US
Practice Address - Phone:907-861-6000
Practice Address - Fax:888-497-1565
Is Sole Proprietor?:No
Enumeration Date:2015-04-14
Last Update Date:2018-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK127958207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine