Provider Demographics
NPI:1386957868
Name:GOSE, KELLY JON
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:JON
Last Name:GOSE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:507 W BENEDICT ST
Mailing Address - Street 2:
Mailing Address - City:SHAWNEE
Mailing Address - State:OK
Mailing Address - Zip Code:74801-6005
Mailing Address - Country:US
Mailing Address - Phone:405-273-6203
Mailing Address - Fax:405-273-6220
Practice Address - Street 1:507 W BENEDICT ST
Practice Address - Street 2:
Practice Address - City:SHAWNEE
Practice Address - State:OK
Practice Address - Zip Code:74801-6005
Practice Address - Country:US
Practice Address - Phone:405-273-6203
Practice Address - Fax:405-273-6220
Is Sole Proprietor?:No
Enumeration Date:2010-07-26
Last Update Date:2010-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK1020237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist