Provider Demographics
NPI:1568262558
Name:KIESLING, BRENTLY C
Entity type:Individual
Prefix:
First Name:BRENTLY
Middle Name:C
Last Name:KIESLING
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:544 S PINE ST
Mailing Address - Street 2:
Mailing Address - City:NOWATA
Mailing Address - State:OK
Mailing Address - Zip Code:74048-4020
Mailing Address - Country:US
Mailing Address - Phone:918-915-1112
Mailing Address - Fax:
Practice Address - Street 1:544 S PINE ST
Practice Address - Street 2:
Practice Address - City:NOWATA
Practice Address - State:OK
Practice Address - Zip Code:74048-4020
Practice Address - Country:US
Practice Address - Phone:918-915-1112
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-03-18
Last Update Date:2025-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes175T00000XOther Service ProvidersPeer SpecialistGroup - Single Specialty