Healthcare Provider Details

I. General information

NPI: 1639994668
Provider Name (Legal Business Name): KENNEDY BARRETT APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/15/2024
Last Update Date: 01/22/2025
Certification Date: 01/22/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4651 N HARRISON ST
SHAWNEE OK
74804-1440
US

IV. Provider business mailing address

777 NW 63RD ST FL 4TH
OKLAHOMA CITY OK
73116-7601
US

V. Phone/Fax

Practice location:
  • Phone: 405-395-5655
  • Fax: 405-395-5654
Mailing address:
  • Phone: 405-272-6193
  • Fax: 405-272-7455

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number220145
License Number StateOK
# 2
Primary TaxonomyY
Taxonomy Code363LW0102X
TaxonomyWomen's Health Nurse Practitioner
License Number220145
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: