Provider Demographics
NPI:1659636520
Name:HENRY, KELLI M (MED)
Entity type:Individual
Prefix:
First Name:KELLI
Middle Name:M
Last Name:HENRY
Suffix:
Gender:F
Credentials:MED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:743 HIGHLAND PKWY
Mailing Address - Street 2:
Mailing Address - City:NORMAN
Mailing Address - State:OK
Mailing Address - Zip Code:73069-7525
Mailing Address - Country:US
Mailing Address - Phone:405-496-9790
Mailing Address - Fax:
Practice Address - Street 1:220 E COMANCHE AVE
Practice Address - Street 2:
Practice Address - City:MCALESTER
Practice Address - State:OK
Practice Address - Zip Code:74501-5846
Practice Address - Country:US
Practice Address - Phone:918-426-5206
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-06
Last Update Date:2012-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor