Healthcare Provider Details

I. General information

NPI: 1891308532
Provider Name (Legal Business Name): KRISTY MCKINNIE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/24/2020
Last Update Date: 08/24/2020
Certification Date: 08/24/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6161 S YALE AVE
TULSA OK
74136-1902
US

IV. Provider business mailing address

11313 N 165TH EAST AVE
OWASSO OK
74055-5784
US

V. Phone/Fax

Practice location:
  • Phone: 918-494-2200
  • Fax:
Mailing address:
  • Phone: 918-636-4286
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number108311
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: