Healthcare Provider Details

I. General information

NPI: 1346650397
Provider Name (Legal Business Name): KAYTI MOXLEY APRN-CNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: KAYTI MONTGOMERY

II. Dates (important events)

Enumeration Date: 04/30/2014
Last Update Date: 11/24/2025
Certification Date: 11/24/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

122 E GRAND AVE
PONCA CITY OK
74601-5205
US

IV. Provider business mailing address

212 N MAIN ST
FAIRFAX OK
74637-3023
US

V. Phone/Fax

Practice location:
  • Phone: 580-302-8270
  • Fax: 580-749-5682
Mailing address:
  • Phone: 918-642-3100
  • Fax: 918-642-5639

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberR0058951
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: