Provider Demographics
NPI:1225545502
Name:DOTY, KELSEY JO (AA)
Entity type:Individual
Prefix:
First Name:KELSEY
Middle Name:JO
Last Name:DOTY
Suffix:
Gender:F
Credentials:AA
Other - Prefix:
Other - First Name:KELSEY
Other - Middle Name:JO
Other - Last Name:GRAHAM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:777 E 15TH ST APT 335
Mailing Address - Street 2:
Mailing Address - City:EDMOND
Mailing Address - State:OK
Mailing Address - Zip Code:73013-5018
Mailing Address - Country:US
Mailing Address - Phone:918-864-3019
Mailing Address - Fax:
Practice Address - Street 1:100 N UNIVERSITY DR
Practice Address - Street 2:
Practice Address - City:EDMOND
Practice Address - State:OK
Practice Address - Zip Code:73034-5207
Practice Address - Country:US
Practice Address - Phone:918-864-3019
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-01-08
Last Update Date:2018-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK7422255A2300X, 390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer