Healthcare Provider Details

I. General information

NPI: 1073000741
Provider Name (Legal Business Name): KELSEY WYER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/18/2018
Last Update Date: 08/09/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14715 BRISTOL PARK BLVD
EDMOND OK
73013
US

IV. Provider business mailing address

14715 BRISTOL PARK BLVD
EDMOND OK
73013-1894
US

V. Phone/Fax

Practice location:
  • Phone: 405-840-1686
  • Fax: 405-840-1006
Mailing address:
  • Phone: 405-840-1686
  • Fax: 405-840-1006

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number4989
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: