Healthcare Provider Details

I. General information

NPI: 1437796711
Provider Name (Legal Business Name): KELLY WHITE CNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/05/2019
Last Update Date: 06/08/2023
Certification Date: 06/08/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11911 S MEMORIAL DR
BIXBY OK
74008-2030
US

IV. Provider business mailing address

PO BOX 334
BIXBY OK
74008-0334
US

V. Phone/Fax

Practice location:
  • Phone: 918-943-3790
  • Fax: 918-943-3793
Mailing address:
  • Phone: 918-970-4719
  • Fax: 918-970-4008

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number96367
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: