Provider Demographics
NPI:1700014867
Name:DECKER-WALTERS, KENNEDY BROOKE (ARNP)
Entity Type:Individual
Prefix:MRS
First Name:KENNEDY
Middle Name:BROOKE
Last Name:DECKER-WALTERS
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:MISS
Other - First Name:KENNEDY
Other - Middle Name:BROOKE
Other - Last Name:DECKER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN
Mailing Address - Street 1:1708 DELIVERY LANE
Mailing Address - Street 2:
Mailing Address - City:DURANT
Mailing Address - State:OK
Mailing Address - Zip Code:74701-2292
Mailing Address - Country:US
Mailing Address - Phone:580-924-5622
Mailing Address - Fax:580-745-5060
Practice Address - Street 1:1708 DELIVERY LANE
Practice Address - Street 2:
Practice Address - City:DURANT
Practice Address - State:OK
Practice Address - Zip Code:74701-2292
Practice Address - Country:US
Practice Address - Phone:580-924-5622
Practice Address - Fax:580-745-5060
Is Sole Proprietor?:No
Enumeration Date:2009-06-29
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX734236163W00000X
OK83279163W00000X
OKR0083279363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse