Individual
KELLY J WALWORTH
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
PAC
Contact information
Practice address
13174 N MACARTHUR BLVD, OKLAHOMA CITY, OK 73142-3017
(405) 721-5555
(405) 470-7093
Mailing address
DEPT 96-0317, OKLAHOMA CITY, OK 73196-0317
(405) 521-1969
(405) 521-1979
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
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