Provider Demographics
NPI:1285695403
Name:KELLEY, MICHELLE (MD)
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:
Last Name:KELLEY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4415 S HARVARD AVE STE 209
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74135-2618
Mailing Address - Country:US
Mailing Address - Phone:539-202-1585
Mailing Address - Fax:539-202-1588
Practice Address - Street 1:4415 S HARVARD AVE STE 209
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74135-2618
Practice Address - Country:US
Practice Address - Phone:539-202-1585
Practice Address - Fax:539-202-1588
Is Sole Proprietor?:No
Enumeration Date:2006-03-29
Last Update Date:2020-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK20270207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100256150BMedicaid
OK249225902Medicare PIN
OKG53751Medicare UPIN