Healthcare Provider Details

I. General information

NPI: 1003346123
Provider Name (Legal Business Name): KELLY LYNN CHESSER APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: KELLY LYNN GREEN

II. Dates (important events)

Enumeration Date: 06/13/2017
Last Update Date: 06/13/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

704 S 8TH ST
MCLOUD OK
74851-8633
US

IV. Provider business mailing address

PO BOX 258884
OKLAHOMA CITY OK
73125-8884
US

V. Phone/Fax

Practice location:
  • Phone: 405-964-6463
  • Fax: 405-964-2412
Mailing address:
  • Phone: 405-231-3857
  • Fax: 405-272-7977

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number75184
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: