Healthcare Provider Details

I. General information

NPI: 1265019863
Provider Name (Legal Business Name): KELLEY MARIE HARRIS DO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/28/2021
Last Update Date: 04/14/2023
Certification Date: 04/14/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

744 W 9TH ST
TULSA OK
74127-9907
US

IV. Provider business mailing address

307 AUTUMNWOOD DR
RUSSELLVILLE AR
72802-7972
US

V. Phone/Fax

Practice location:
  • Phone: 918-599-1000
  • Fax:
Mailing address:
  • Phone: 479-651-1685
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number1265019863
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: