Provider Demographics
NPI:1861888414
Name:KELLEY, BRENDA (PA)
Entity type:Individual
Prefix:
First Name:BRENDA
Middle Name:
Last Name:KELLEY
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 429
Mailing Address - Street 2:
Mailing Address - City:NORMAN
Mailing Address - State:OK
Mailing Address - Zip Code:73070-0429
Mailing Address - Country:US
Mailing Address - Phone:405-360-1119
Mailing Address - Fax:405-360-7177
Practice Address - Street 1:500 E ROBINSON ST
Practice Address - Street 2:SUITE 300
Practice Address - City:NORMAN
Practice Address - State:OK
Practice Address - Zip Code:73071-6697
Practice Address - Country:US
Practice Address - Phone:405-360-1119
Practice Address - Fax:405-360-7177
Is Sole Proprietor?:No
Enumeration Date:2015-04-10
Last Update Date:2015-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK2507363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant