Healthcare Provider Details

I. General information

NPI: 1851121826
Provider Name (Legal Business Name): ALICE KEITHLY
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/05/2024
Last Update Date: 06/11/2026
Certification Date: 06/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2615 E RANDOLPH AVE
ENID OK
73701-4670
US

IV. Provider business mailing address

8025 N 30TH ST
ENID OK
73701-6864
US

V. Phone/Fax

Practice location:
  • Phone: 580-234-3734
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code231H00000X
TaxonomyAudiologist
License Number2505
License Number StateKS
# 2
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: