Healthcare Provider Details

I. General information

NPI: 1134952419
Provider Name (Legal Business Name): KEYANNDRA NICHELLE YOUNG
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/22/2024
Last Update Date: 12/08/2025
Certification Date: 12/08/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3555 NW 58TH ST STE 140-W
OKLAHOMA CITY OK
73112-4707
US

IV. Provider business mailing address

3555 NW 58TH ST STE 140-W
OKLAHOMA CITY OK
73112-4707
US

V. Phone/Fax

Practice location:
  • Phone: 405-450-7167
  • Fax:
Mailing address:
  • Phone: 405-450-7167
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number219906
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: