Healthcare Provider Details

I. General information

NPI: 1760925002
Provider Name (Legal Business Name): KELSEY KOEHLER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/18/2016
Last Update Date: 03/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2525 GLENN HENDREN DR
LIBERTY MO
64068-9625
US

IV. Provider business mailing address

1923 S UTICA AVE
TULSA OK
74104-6520
US

V. Phone/Fax

Practice location:
  • Phone: 913-642-4900
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code367H00000X
TaxonomyAnesthesiologist Assistant
License Number2017017187
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: