Healthcare Provider Details

I. General information

NPI: 1346828829
Provider Name (Legal Business Name): ELISE KENNEDY
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/29/2021
Last Update Date: 08/12/2026
Certification Date: 08/12/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

209 LILAC DR STE 130
EDMOND OK
73034-7208
US

IV. Provider business mailing address

277 SW 6TH ST APT F4
JONES OK
73049-7569
US

V. Phone/Fax

Practice location:
  • Phone: 405-295-5753
  • Fax:
Mailing address:
  • Phone: 479-719-8916
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2355S0801X
TaxonomySpeech-Language Assistant
License NumberSLPA151
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: