Individual
KELLY J WALWORTH
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
PAC
Taxonomy
Speciality
Code
Description
License number
State
363AM0700X
Medical Physician Assistant
Primary
1460
OK
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
1710198569
GROUP NPI
OK
05
—
200265130A
—
OK
Enumeration date
11/21/2005
Last updated
07/21/2022
Update your record
If you believe information in your NPPES record is inaccurate, or if you wish to update or deactivate your NPI, you can do so directly with CMS at https://nppes.cms.hhs.gov.
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