Provider Demographics
NPI:1104199470
Name:FARRELL, KISHA MARIE (APRN FNP-BC)
Entity Type:Individual
Prefix:
First Name:KISHA
Middle Name:MARIE
Last Name:FARRELL
Suffix:
Gender:F
Credentials:APRN FNP-BC
Other - Prefix:
Other - First Name:KISHA
Other - Middle Name:MARIE
Other - Last Name:BECKWITH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:212 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:FAIRFAX
Mailing Address - State:OK
Mailing Address - Zip Code:74637-3023
Mailing Address - Country:US
Mailing Address - Phone:918-642-3100
Mailing Address - Fax:918-642-5639
Practice Address - Street 1:119 W MAIN ST
Practice Address - Street 2:
Practice Address - City:HOMINY
Practice Address - State:OK
Practice Address - Zip Code:74035-1031
Practice Address - Country:US
Practice Address - Phone:918-885-4640
Practice Address - Fax:918-885-4644
Is Sole Proprietor?:No
Enumeration Date:2012-02-17
Last Update Date:2013-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK72827363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200418760AMedicaid
OKOKAAA3985Medicare PIN