Provider Demographics
NPI:1710519004
Name:SANDERSON, KIMBER MARIE (APRN)
Entity Type:Individual
Prefix:
First Name:KIMBER
Middle Name:MARIE
Last Name:SANDERSON
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:KIMBER
Other - Middle Name:MARIE
Other - Last Name:SANDERSON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:APRN
Mailing Address - Street 1:15501 MULBERRY RD
Mailing Address - Street 2:
Mailing Address - City:HENRYETTA
Mailing Address - State:OK
Mailing Address - Zip Code:74437-8112
Mailing Address - Country:US
Mailing Address - Phone:405-584-1071
Mailing Address - Fax:405-786-2589
Practice Address - Street 1:315 W 9TH ST
Practice Address - Street 2:
Practice Address - City:WELEETKA
Practice Address - State:OK
Practice Address - Zip Code:74880-8117
Practice Address - Country:US
Practice Address - Phone:405-786-2248
Practice Address - Fax:405-786-2006
Is Sole Proprietor?:No
Enumeration Date:2020-02-05
Last Update Date:2023-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKR0111358163WG0600X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163WG0600XNursing Service ProvidersRegistered NurseGerontology