Healthcare Provider Details

I. General information

NPI: 1225672496
Provider Name (Legal Business Name): KATHLEEN BETH CONNELLY
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/31/2019
Last Update Date: 10/31/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

921 NE 13TH ST
OKLAHOMA CITY OK
73104-5007
US

IV. Provider business mailing address

1505 MEAD LN
OKLAHOMA CITY OK
73170-1466
US

V. Phone/Fax

Practice location:
  • Phone: 405-456-3859
  • Fax:
Mailing address:
  • Phone: 405-410-4147
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberR0040928
License Number StateOK
# 2
Primary TaxonomyY
Taxonomy Code246X00000X
TaxonomyCardiovascular Specialist/Technologist
License Number102399
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: