Healthcare Provider Details

I. General information

NPI: 1326527060
Provider Name (Legal Business Name): KELLY ANN WATSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/13/2018
Last Update Date: 07/07/2026
Certification Date: 07/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4812 S 109TH EAST AVE
TULSA OK
74146-5826
US

IV. Provider business mailing address

6502 S YALE AVE STE 3410
TULSA OK
74136-8329
US

V. Phone/Fax

Practice location:
  • Phone: 918-236-4500
  • Fax: 918-436-4501
Mailing address:
  • Phone: 918-499-4855
  • Fax: 918-488-6098

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License Number118006
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: