Provider Demographics
NPI:1396258562
Name:WILSON, KELLIE ANN
Entity type:Individual
Prefix:
First Name:KELLIE
Middle Name:ANN
Last Name:WILSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:KELLIE
Other - Middle Name:ANN
Other - Last Name:BAILEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:11006 S JAMES CT
Mailing Address - Street 2:
Mailing Address - City:JENKS
Mailing Address - State:OK
Mailing Address - Zip Code:74037-1663
Mailing Address - Country:US
Mailing Address - Phone:918-949-0960
Mailing Address - Fax:
Practice Address - Street 1:7010 S YALE AVE STE 215
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74136-5743
Practice Address - Country:US
Practice Address - Phone:918-492-2554
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-11-10
Last Update Date:2017-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical