Provider Demographics
NPI:1164279469
Name:OOLOGAH PEDIATRIC CARE, PLLC
Entity type:Organization
Organization Name:OOLOGAH PEDIATRIC CARE, PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KELSEY
Authorized Official - Middle Name:
Authorized Official - Last Name:LILLARD
Authorized Official - Suffix:
Authorized Official - Credentials:APRN, CPNP-PC
Authorized Official - Phone:469-915-4211
Mailing Address - Street 1:PO BOX 622
Mailing Address - Street 2:
Mailing Address - City:OOLOGAH
Mailing Address - State:OK
Mailing Address - Zip Code:74053-0622
Mailing Address - Country:US
Mailing Address - Phone:918-376-3299
Mailing Address - Fax:
Practice Address - Street 1:115 W. ATLAS AVENUE
Practice Address - Street 2:
Practice Address - City:OOLOGAH
Practice Address - State:OK
Practice Address - Zip Code:74053
Practice Address - Country:US
Practice Address - Phone:918-376-3299
Practice Address - Fax:918-332-9950
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-05-03
Last Update Date:2024-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatricsGroup - Single Specialty