Healthcare Provider Details

I. General information

NPI: 1578509378
Provider Name (Legal Business Name): VANESSA L KENNISON ARNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: VANESSA L IRBY RN, MSN, ARNP, FNP-C

II. Dates (important events)

Enumeration Date: 06/21/2006
Last Update Date: 02/10/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1120 S UTICA AVE SUITE 3074
TULSA OK
74104-4012
US

IV. Provider business mailing address

1120 S UTICA AVE SUITE 3074
TULSA OK
74104-4012
US

V. Phone/Fax

Practice location:
  • Phone: 918-579-7100
  • Fax: 918-579-7110
Mailing address:
  • Phone: 918-579-7100
  • Fax: 918-579-7110

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberR0062587
License Number StateOK
# 2
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberR0062587
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: