MEDICARE: MRS. KIMMI JO STANLEY MS,CCC-SLP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	235Z00000X	Speech-Language Pathologist	2839	OK

General Provider Information

NPI Number	:	1841500113
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. KIMMI JO STANLEY MS,CCC-SLP

Provider Business Mailing Address
First Line	:	9400 ST. ANN'S HOME
Second Line	:
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73162
Country	:	US
Telephone Number	:	405-470-6953
Fax Number	:	405-470-6953

Provider Business Practice Location Address
First Line	:	9400 ST. ANN'S HOME
Second Line	:
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73162
Country	:	US
Telephone Number	:	405-470-6953
Fax Number	:	405-470-6953

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/20/2010
Last Update Date	:	10/20/2010

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