Healthcare Provider Details

I. General information

NPI: 1629954896
Provider Name (Legal Business Name): KELLEY MARICLE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/13/2025
Last Update Date: 08/13/2025
Certification Date: 08/13/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1728 S CARSON AVE
TULSA OK
74119-4610
US

IV. Provider business mailing address

2104 W H ST
JENKS OK
74037-2355
US

V. Phone/Fax

Practice location:
  • Phone: 918-637-9937
  • Fax:
Mailing address:
  • Phone: 918-637-9937
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: