Provider Demographics
NPI:1043800196
Name:O'DIAM, KYMBRYNN NICOLE (APRN)
Entity Type:Individual
Prefix:
First Name:KYMBRYNN
Middle Name:NICOLE
Last Name:O'DIAM
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:KYMBRYNN
Other - Middle Name:NICOLE
Other - Last Name:HENNEKE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:101 OKLAHOMA AVE
Mailing Address - Street 2:
Mailing Address - City:MCALESTER
Mailing Address - State:OK
Mailing Address - Zip Code:74501-7520
Mailing Address - Country:US
Mailing Address - Phone:918-423-4900
Mailing Address - Fax:
Practice Address - Street 1:101 OKLAHOMA AVE
Practice Address - Street 2:
Practice Address - City:MCALESTER
Practice Address - State:OK
Practice Address - Zip Code:74501-7520
Practice Address - Country:US
Practice Address - Phone:918-423-4900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-01-22
Last Update Date:2022-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK200856363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily