Provider Demographics
NPI:1891108593
Name:COLBERT, KRISTEN DYAN
Entity Type:Individual
Prefix:
First Name:KRISTEN
Middle Name:DYAN
Last Name:COLBERT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:KRISTEN
Other - Middle Name:DYAN
Other - Last Name:KERR
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:APRN
Mailing Address - Street 1:1313 E 20TH ST
Mailing Address - Street 2:
Mailing Address - City:OKMULGEE
Mailing Address - State:OK
Mailing Address - Zip Code:74447-6303
Mailing Address - Country:US
Mailing Address - Phone:918-591-5762
Mailing Address - Fax:
Practice Address - Street 1:1313 E 20TH ST
Practice Address - Street 2:
Practice Address - City:OKMULGEE
Practice Address - State:OK
Practice Address - Zip Code:74447-6303
Practice Address - Country:US
Practice Address - Phone:918-591-5762
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-06-10
Last Update Date:2014-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK89068363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily