Provider Demographics
NPI:1396382883
Name:REDICK, KALEB (RN, BSN FNP)
Entity Type:Individual
Prefix:
First Name:KALEB
Middle Name:
Last Name:REDICK
Suffix:
Gender:M
Credentials:RN, BSN FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1201 COVELL VILLAGE DR APT 330
Mailing Address - Street 2:
Mailing Address - City:EDMOND
Mailing Address - State:OK
Mailing Address - Zip Code:73003-9720
Mailing Address - Country:US
Mailing Address - Phone:405-613-0502
Mailing Address - Fax:
Practice Address - Street 1:1620 E 12TH ST
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74120-5407
Practice Address - Country:US
Practice Address - Phone:918-582-2131
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-12-04
Last Update Date:2019-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK113244363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily