Provider Demographics
NPI:1235940164
Name:BOURELL, KALISTE CAMILE
Entity type:Individual
Prefix:
First Name:KALISTE
Middle Name:CAMILE
Last Name:BOURELL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6400 N ANN ARBOR AVE
Mailing Address - Street 2:
Mailing Address - City:WARR ACRES
Mailing Address - State:OK
Mailing Address - Zip Code:73132-7705
Mailing Address - Country:US
Mailing Address - Phone:405-428-2866
Mailing Address - Fax:
Practice Address - Street 1:6400 N ANN ARBOR AVE
Practice Address - Street 2:
Practice Address - City:WARR ACRES
Practice Address - State:OK
Practice Address - Zip Code:73132-7705
Practice Address - Country:US
Practice Address - Phone:405-428-2866
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-01-20
Last Update Date:2025-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist