Provider Demographics
NPI:1508697889
Name:KINKAID, HEATHER
Entity type:Individual
Prefix:
First Name:HEATHER
Middle Name:
Last Name:KINKAID
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 1:2320 DRAKE LN
Mailing Address - Street 2:
Mailing Address - City:PONCA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:74604-2749
Mailing Address - Country:US
Mailing Address - Phone:918-331-8342
Mailing Address - Fax:
Practice Address - Street 1:2320 DRAKE LN
Practice Address - Street 2:
Practice Address - City:PONCA CITY
Practice Address - State:OK
Practice Address - Zip Code:74604-2749
Practice Address - Country:US
Practice Address - Phone:918-331-8342
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-08-09
Last Update Date:2024-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKL0068393164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse