Healthcare Provider Details

I. General information

NPI: 1295616944
Provider Name (Legal Business Name): AUDREY MCKENNA CST, CSFA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/09/2025
Last Update Date: 09/09/2025
Certification Date: 09/09/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1120 S UTICA AVE
TULSA OK
74104-4090
US

IV. Provider business mailing address

6411 W 103RD ST N
SPERRY OK
74073-4184
US

V. Phone/Fax

Practice location:
  • Phone: 918-764-5718
  • Fax:
Mailing address:
  • Phone: 918-764-5718
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code246ZC0007X
TaxonomySurgical Assistant
License Number100265306
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: