Healthcare Provider Details

I. General information

NPI: 1376137141
Provider Name (Legal Business Name): KORISSA GILLESPIE APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/23/2021
Last Update Date: 12/16/2024
Certification Date: 12/16/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6161 S YALE AVE
TULSA OK
74136-1902
US

IV. Provider business mailing address

6600 S YALE AVE STE 1200
TULSA OK
74136-3361
US

V. Phone/Fax

Practice location:
  • Phone: 918-494-1418
  • Fax: 918-728-8036
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number79620
License Number StateKS
# 2
Primary TaxonomyY
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License Number219847
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: