Healthcare Provider Details

I. General information

NPI: 1154945285
Provider Name (Legal Business Name): MARY KEKAHBAH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/04/2020
Last Update Date: 06/04/2020
Certification Date: 06/04/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

129 CONNER RD
HOMINY OK
74035-2100
US

IV. Provider business mailing address

1121 ROGERS AVE
PAWHUSKA OK
74056-3046
US

V. Phone/Fax

Practice location:
  • Phone: 918-594-1300
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberAG02200097
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: