Provider Demographics
NPI:1184165557
Name:KINKEADE, ANDREA
Entity type:Individual
Prefix:
First Name:ANDREA
Middle Name:
Last Name:KINKEADE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:521 E FORT WORTH DR
Mailing Address - Street 2:
Mailing Address - City:BROKEN ARROW
Mailing Address - State:OK
Mailing Address - Zip Code:74012-4314
Mailing Address - Country:US
Mailing Address - Phone:918-574-1004
Mailing Address - Fax:
Practice Address - Street 1:521 E FORT WORTH DR
Practice Address - Street 2:
Practice Address - City:BROKEN ARROW
Practice Address - State:OK
Practice Address - Zip Code:74012-4314
Practice Address - Country:US
Practice Address - Phone:918-574-1004
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-03-17
Last Update Date:2017-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program