Provider Demographics
NPI:1114954500
Name:SCAFFETTA, KIMBERLY M (AUD)
Entity Type:Individual
Prefix:DR
First Name:KIMBERLY
Middle Name:M
Last Name:SCAFFETTA
Suffix:
Gender:F
Credentials:AUD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2017 S ELM PL
Mailing Address - Street 2:SUITE 107
Mailing Address - City:BROKEN ARROW
Mailing Address - State:OK
Mailing Address - Zip Code:74012-7034
Mailing Address - Country:US
Mailing Address - Phone:918-451-3277
Mailing Address - Fax:918-455-3891
Practice Address - Street 1:2017 S ELM PL
Practice Address - Street 2:SUITE 107
Practice Address - City:BROKEN ARROW
Practice Address - State:OK
Practice Address - Zip Code:74012-7034
Practice Address - Country:US
Practice Address - Phone:918-451-3277
Practice Address - Fax:918-455-3891
Is Sole Proprietor?:No
Enumeration Date:2006-06-28
Last Update Date:2008-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK267231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100670480Medicaid
OK800522188Medicare NSC