Healthcare Provider Details

I. General information

NPI: 1316057102
Provider Name (Legal Business Name): KELLI L SCHENK RD/LD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/30/2006
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 W 7TH ST
HENNESSEY OK
73742-1711
US

IV. Provider business mailing address

200 W 7TH ST
HENNESSEY OK
73742-1711
US

V. Phone/Fax

Practice location:
  • Phone: 405-853-4671
  • Fax: 405-853-4671
Mailing address:
  • Phone: 405-853-4671
  • Fax: 405-853-4671

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133N00000X
TaxonomyNutritionist
License Number1188
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: