Provider Demographics
NPI:1871104810
Name:GREEN, KELLYE F
Entity type:Individual
Prefix:
First Name:KELLYE
Middle Name:F
Last Name:GREEN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:KELLYE
Other - Middle Name:F
Other - Last Name:FERGUSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4400 N LINCOLN BLVD
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73105-5104
Mailing Address - Country:US
Mailing Address - Phone:580-379-4085
Mailing Address - Fax:
Practice Address - Street 1:111 N HUDSON ST
Practice Address - Street 2:
Practice Address - City:ALTUS
Practice Address - State:OK
Practice Address - Zip Code:73521-3811
Practice Address - Country:US
Practice Address - Phone:580-379-4085
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-13
Last Update Date:2020-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist