MEDICARE: KAITLIN AILENE ISLEY D.O.

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	390200000X	Student in an Organized Health Care Education/Training Program

General Provider Information

NPI Number	:	1891139770
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KAITLIN AILENE ISLEY D.O.

Provider Business Mailing Address
First Line	:	4502 E 41ST ST
Second Line	:
City	:	TULSA
State	:	OK
Zip	:	74135-2512
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	4502 E 41ST ST
Second Line	:
City	:	TULSA
State	:	OK
Zip	:	74135-2512
Country	:	US
Telephone Number	:	918-660-3000
Fax Number	:

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

Provider Enumeration Date	:	04/23/2013
Last Update Date	:	04/23/2013

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