Provider Demographics
NPI:1194061143
Name:HUMPHREYS, KALLIE BLYTHE (PA-C)
Entity type:Individual
Prefix:MRS
First Name:KALLIE
Middle Name:BLYTHE
Last Name:HUMPHREYS
Suffix:
Gender:F
Credentials:PA-C
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 269032
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73126-9032
Mailing Address - Country:US
Mailing Address - Phone:405-951-2545
Mailing Address - Fax:
Practice Address - Street 1:3300 NW EXPRESSWAY
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73112-4999
Practice Address - Country:US
Practice Address - Phone:405-949-3011
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-12-19
Last Update Date:2022-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKAPA2188363AM0700X
OK2188363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical