Provider Demographics
NPI:1952971343
Name:VILLALON, KENNEDY BROOKE
Entity Type:Individual
Prefix:
First Name:KENNEDY
Middle Name:BROOKE
Last Name:VILLALON
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 1:2732 KENT DR
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73120-2922
Mailing Address - Country:US
Mailing Address - Phone:580-606-3511
Mailing Address - Fax:
Practice Address - Street 1:200 NW 66TH ST
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73116-8256
Practice Address - Country:US
Practice Address - Phone:405-286-3749
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-28
Last Update Date:2021-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK5581225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK5581Medicaid