Provider Demographics
NPI:1982244695
Name:PETREE, KELLY JANELL
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:JANELL
Last Name:PETREE
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 1:9228 S MINGO RD STE 101&103
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74133-5718
Mailing Address - Country:US
Mailing Address - Phone:405-378-2727
Mailing Address - Fax:918-518-7258
Practice Address - Street 1:9228 S MINGO RD STE 101&103
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74133-5718
Practice Address - Country:US
Practice Address - Phone:405-378-2727
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-01-10
Last Update Date:2023-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2020000885363LP0808X
OK212074363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO420080198Medicaid