Provider Demographics
NPI:1437987492
Name:LEWIS, KELLY (RN)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:LEWIS
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:711 S MUSKOGEE AVE
Mailing Address - Street 2:
Mailing Address - City:TAHLEQUAH
Mailing Address - State:OK
Mailing Address - Zip Code:74464-4717
Mailing Address - Country:US
Mailing Address - Phone:918-207-0078
Mailing Address - Fax:918-207-0558
Practice Address - Street 1:711 S MUSKOGEE AVE
Practice Address - Street 2:
Practice Address - City:TAHLEQUAH
Practice Address - State:OK
Practice Address - Zip Code:74464-4717
Practice Address - Country:US
Practice Address - Phone:918-207-0078
Practice Address - Fax:918-207-0558
Is Sole Proprietor?:Yes
Enumeration Date:2024-07-22
Last Update Date:2024-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKR0122687163WP0809X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WP0809XNursing Service ProvidersRegistered NursePsychiatric/Mental Health, Adult