Provider Demographics
NPI:1639837099
Name:SULLIVAN, KIMBERLY KAY (APRN, FNP-C)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:KAY
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:APRN, FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:550 COUNTRY CLUB RD
Mailing Address - Street 2:
Mailing Address - City:POTEAU
Mailing Address - State:OK
Mailing Address - Zip Code:74953-5219
Mailing Address - Country:US
Mailing Address - Phone:417-848-7976
Mailing Address - Fax:
Practice Address - Street 1:1001 N BROADWAY ST
Practice Address - Street 2:
Practice Address - City:POTEAU
Practice Address - State:OK
Practice Address - Zip Code:74953-2609
Practice Address - Country:US
Practice Address - Phone:918-649-0731
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-12-02
Last Update Date:2022-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKR0040317363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily