Provider Demographics
NPI:1881105161
Name:KIMBRELL, KELLY R (APRN)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:R
Last Name:KIMBRELL
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4140 W MEMORIAL RD STE 215
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73120-8361
Mailing Address - Country:US
Mailing Address - Phone:405-242-4030
Mailing Address - Fax:405-242-4031
Practice Address - Street 1:4140 W MEMORIAL RD STE 215
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73120-8361
Practice Address - Country:US
Practice Address - Phone:405-242-4030
Practice Address - Fax:405-242-4031
Is Sole Proprietor?:No
Enumeration Date:2017-10-13
Last Update Date:2018-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK101588363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily