Provider Demographics
NPI:1518421841
Name:KELLY, KYLAH CHEYENNE (COTA)
Entity type:Individual
Prefix:MRS
First Name:KYLAH
Middle Name:CHEYENNE
Last Name:KELLY
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:405 CAMPBELL ST
Mailing Address - Street 2:
Mailing Address - City:BROKEN BOW
Mailing Address - State:OK
Mailing Address - Zip Code:74728-3143
Mailing Address - Country:US
Mailing Address - Phone:580-236-4625
Mailing Address - Fax:
Practice Address - Street 1:405 CAMPBELL ST
Practice Address - Street 2:
Practice Address - City:BROKEN BOW
Practice Address - State:OK
Practice Address - Zip Code:74728-3143
Practice Address - Country:US
Practice Address - Phone:580-236-4625
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-01-31
Last Update Date:2019-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK2072224Z00000X
TX215590224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant