Provider Demographics
NPI:1316430994
Name:ACOSTA, KELLY (LPN)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:ACOSTA
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:
Other - Last Name:ANDERSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LPN
Mailing Address - Street 1:4913 W RENO AVE
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73127-6339
Mailing Address - Country:US
Mailing Address - Phone:405-948-4900
Mailing Address - Fax:405-948-4919
Practice Address - Street 1:4913 W RENO AVE
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73127-6339
Practice Address - Country:US
Practice Address - Phone:405-948-4900
Practice Address - Fax:405-948-4919
Is Sole Proprietor?:No
Enumeration Date:2018-06-08
Last Update Date:2018-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK67033164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse