Healthcare Provider Details

I. General information

NPI: 1396258562
Provider Name (Legal Business Name): KELLIE ANN WILSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: KELLIE ANN BAILEY

II. Dates (important events)

Enumeration Date: 11/10/2017
Last Update Date: 11/10/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7010 S YALE AVE STE 215
TULSA OK
74136-5743
US

IV. Provider business mailing address

11006 S JAMES CT
JENKS OK
74037-1663
US

V. Phone/Fax

Practice location:
  • Phone: 918-492-2554
  • Fax:
Mailing address:
  • Phone: 918-949-0960
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: