Provider Demographics
NPI:1194145474
Name:KELSAY, MALLORY (ATC)
Entity type:Individual
Prefix:
First Name:MALLORY
Middle Name:
Last Name:KELSAY
Suffix:
Gender:F
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:800 TUCKER DR
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74104-9700
Mailing Address - Country:US
Mailing Address - Phone:918-631-5259
Mailing Address - Fax:918-631-3057
Practice Address - Street 1:800 TUCKER DR
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74104-9700
Practice Address - Country:US
Practice Address - Phone:918-631-5259
Practice Address - Fax:918-631-3057
Is Sole Proprietor?:No
Enumeration Date:2014-04-24
Last Update Date:2014-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK7342255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer