Healthcare Provider Details

I. General information

NPI: 1487144374
Provider Name (Legal Business Name): KIMBERLY GALE HENRY
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/16/2018
Last Update Date: 05/16/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16305 E GRAND MEADOW DR.
CLAREMORE OK
74017
US

IV. Provider business mailing address

PO BOX 1211
CLAREMORE OK
74018-1211
US

V. Phone/Fax

Practice location:
  • Phone: 918-857-1478
  • 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 State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: