Provider Demographics
NPI:1962878850
Name:KELLY, MARILYN RUTH
Entity type:Individual
Prefix:MRS
First Name:MARILYN
Middle Name:RUTH
Last Name:KELLY
Suffix:
Gender:F
Credentials:
Other - Prefix:MS
Other - First Name:MARILYN
Other - Middle Name:RUTH
Other - Last Name:MAZZUCA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4400 N LINCOLN BLVD
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73105-5108
Mailing Address - Country:US
Mailing Address - Phone:405-424-7711
Mailing Address - Fax:
Practice Address - Street 1:94 N 31ST ST
Practice Address - Street 2:
Practice Address - City:CLINTON
Practice Address - State:OK
Practice Address - Zip Code:73601-9116
Practice Address - Country:US
Practice Address - Phone:405-424-7711
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-08-14
Last Update Date:2019-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251B00000XAgenciesCase Management