Healthcare Provider Details

I. General information

NPI: 1619631801
Provider Name (Legal Business Name): MRS. KELSEY MICHELLE HAYNES
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/25/2021
Last Update Date: 08/18/2025
Certification Date: 08/18/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8418 N 123RD EAST AVE
OWASSO OK
74055-2139
US

IV. Provider business mailing address

1400 E 380 RD
TALALA OK
74080-3833
US

V. Phone/Fax

Practice location:
  • Phone: 918-858-4353
  • Fax: 866-246-2942
Mailing address:
  • Phone: 918-520-6527
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number4634
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: