MEDICARE: MRS. KELSEY MICHELLE HAYNES

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363A00000X	Physician Assistant	4634	OK

General Provider Information

NPI Number	:	1619631801
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. KELSEY MICHELLE HAYNES

Provider Business Mailing Address
First Line	:	1400 E 380 RD
Second Line	:
City	:	TALALA
State	:	OK
Zip	:	74080-3833
Country	:	US
Telephone Number	:	918-520-6527
Fax Number	:

Provider Business Practice Location Address
First Line	:	8418 N 123RD EAST AVE
Second Line	:
City	:	OWASSO
State	:	OK
Zip	:	74055-2139
Country	:	US
Telephone Number	:	918-858-4353
Fax Number	:	866-246-2942

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/25/2021
Last Update Date	:	08/18/2025

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