Provider Demographics
NPI:1992267017
Name:YBARRA, KELSEY RAE
Entity type:Individual
Prefix:
First Name:KELSEY
Middle Name:RAE
Last Name:YBARRA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:KELSEY
Other - Middle Name:RAE
Other - Last Name:CRAWFORD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:9 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:ARDMORE
Mailing Address - State:OK
Mailing Address - Zip Code:73401-7008
Mailing Address - Country:US
Mailing Address - Phone:940-552-2204
Mailing Address - Fax:
Practice Address - Street 1:9 E MAIN ST
Practice Address - Street 2:
Practice Address - City:ARDMORE
Practice Address - State:OK
Practice Address - Zip Code:73401-7008
Practice Address - Country:US
Practice Address - Phone:580-223-7333
Practice Address - Fax:580-825-0290
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-05
Last Update Date:2023-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX9818TG152W00000X, 332H00000X
OK3019152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
No332H00000XSuppliersEyewear SupplierGroup - Single Specialty