Healthcare Provider Details

I. General information

NPI: 1164283578
Provider Name (Legal Business Name): KELLEY ANNE DAVIDSON APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: KELLEY ANNE DAVIS NP

II. Dates (important events)

Enumeration Date: 01/22/2024
Last Update Date: 10/06/2025
Certification Date: 10/06/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

401 W MAIN ST
HENRYETTA OK
74437-4241
US

IV. Provider business mailing address

401 W MAIN ST
HENRYETTA OK
74437-4241
US

V. Phone/Fax

Practice location:
  • Phone: 539-667-0001
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number1234
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: