Provider Demographics
NPI:1700628781
Name:TEAL, KELLY DIANE I (RN)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:DIANE
Last Name:TEAL
Suffix:I
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 1:617 EDWARDS LN
Mailing Address - Street 2:
Mailing Address - City:INDIANOLA
Mailing Address - State:OK
Mailing Address - Zip Code:74442-5149
Mailing Address - Country:US
Mailing Address - Phone:918-426-7800
Mailing Address - Fax:
Practice Address - Street 1:1101 E MONROE AVE
Practice Address - Street 2:
Practice Address - City:MCALESTER
Practice Address - State:OK
Practice Address - Zip Code:74501-4815
Practice Address - Country:US
Practice Address - Phone:918-426-7800
Practice Address - Fax:918-426-5837
Is Sole Proprietor?:No
Enumeration Date:2024-06-10
Last Update Date:2024-06-11
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
OKR0075252163WC1500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WC1500XNursing Service ProvidersRegistered NurseCommunity Health