Healthcare Provider Details

I. General information

NPI: 1003454067
Provider Name (Legal Business Name): KALYN LEE KHALAF RD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: KALYN LEE SPARKS RD

II. Dates (important events)

Enumeration Date: 12/20/2019
Last Update Date: 12/20/2019
Certification Date: 12/20/2019
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15800 LANGLEY WAY
EDMOND OK
73013-0001
US

IV. Provider business mailing address

15800 LANGLEY WAY
EDMOND OK
73013-0001
US

V. Phone/Fax

Practice location:
  • Phone: 405-361-1040
  • Fax:
Mailing address:
  • Phone: 405-361-1040
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number86062373
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: