Healthcare Provider Details

I. General information

NPI: 1275458929
Provider Name (Legal Business Name): KELLEY MITCHELL
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/12/2026
Last Update Date: 08/12/2026
Certification Date: 08/12/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2615 S 7TH ST
BROKEN ARROW OK
74012-4346
US

IV. Provider business mailing address

2615 S 7TH ST
BROKEN ARROW OK
74012-4346
US

V. Phone/Fax

Practice location:
  • Phone: 918-946-1610
  • Fax:
Mailing address:
  • Phone: 918-577-3939
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number207591
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: