Healthcare Provider Details

I. General information

NPI: 1336004977
Provider Name (Legal Business Name): KENNADI LYNN INGRAM
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/17/2025
Last Update Date: 12/17/2025
Certification Date: 12/16/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

195674 N 4270 RD
ANTLERS OK
74523-7100
US

IV. Provider business mailing address

195674 N 4270 RD
ANTLERS OK
74523-7100
US

V. Phone/Fax

Practice location:
  • Phone: 580-743-6991
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: