Provider Demographics
NPI:1982995791
Name:REID, KELLY (APRN-CNP)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:REID
Suffix:
Gender:F
Credentials:APRN-CNP
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:
Other - Last Name:MIDDLETON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:ARNP
Mailing Address - Street 1:1921 STONECIPHER DR
Mailing Address - Street 2:
Mailing Address - City:ADA
Mailing Address - State:OK
Mailing Address - Zip Code:74820-3439
Mailing Address - Country:US
Mailing Address - Phone:580-436-3980
Mailing Address - Fax:580-272-1026
Practice Address - Street 1:1921 STONECIPHER DR
Practice Address - Street 2:
Practice Address - City:ADA
Practice Address - State:OK
Practice Address - Zip Code:74820-3439
Practice Address - Country:US
Practice Address - Phone:580-436-3980
Practice Address - Fax:580-272-1026
Is Sole Proprietor?:No
Enumeration Date:2011-04-27
Last Update Date:2014-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK60112363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK60112OtherLICENSE