Provider Demographics
NPI:1346995230
Name:KIRK, VERONICA ANTONIA
Entity Type:Individual
Prefix:MRS
First Name:VERONICA
Middle Name:ANTONIA
Last Name:KIRK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1002 2ND ST
Mailing Address - Street 2:
Mailing Address - City:CHATTANOOGA
Mailing Address - State:OK
Mailing Address - Zip Code:73528-2634
Mailing Address - Country:US
Mailing Address - Phone:580-574-0307
Mailing Address - Fax:
Practice Address - Street 1:3401 W GORE BLVD
Practice Address - Street 2:
Practice Address - City:LAWTON
Practice Address - State:OK
Practice Address - Zip Code:73505-6332
Practice Address - Country:US
Practice Address - Phone:580-355-8620
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-02-18
Last Update Date:2022-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK136689367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered