Provider Demographics
NPI:1306335252
Name:LAIL, KRISTEN NICOLE I (MED, RBT)
Entity type:Individual
Prefix:MRS
First Name:KRISTEN
Middle Name:NICOLE
Last Name:LAIL
Suffix:I
Gender:F
Credentials:MED, RBT
Other - Prefix:MRS
Other - First Name:KRISTEN
Other - Middle Name:NICOLE
Other - Last Name:O'CONNOR
Other - Suffix:I
Other - Last Name Type:Former Name
Other - Credentials:MED
Mailing Address - Street 1:1924 NW 176TH TER
Mailing Address - Street 2:
Mailing Address - City:EDMOND
Mailing Address - State:OK
Mailing Address - Zip Code:73012-6981
Mailing Address - Country:US
Mailing Address - Phone:602-290-7952
Mailing Address - Fax:
Practice Address - Street 1:2505 SE LEE BLVD
Practice Address - Street 2:
Practice Address - City:LAWTON
Practice Address - State:OK
Practice Address - Zip Code:73501-6302
Practice Address - Country:US
Practice Address - Phone:907-854-1072
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-07
Last Update Date:2018-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician