Healthcare Provider Details

I. General information

NPI: 1710519004
Provider Name (Legal Business Name): KIMBER MARIE SANDERSON APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: KIMBER MARIE SANDERSON APRN

II. Dates (important events)

Enumeration Date: 02/05/2020
Last Update Date: 08/20/2025
Certification Date: 08/20/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

315 W 9TH ST
WELEETKA OK
74880-8117
US

IV. Provider business mailing address

15501 MULBERRY RD
HENRYETTA OK
74437-8112
US

V. Phone/Fax

Practice location:
  • Phone: 405-786-2248
  • Fax: 405-786-2006
Mailing address:
  • Phone: 405-584-1071
  • Fax: 405-786-2589

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WG0600X
TaxonomyGerontology Registered Nurse
License NumberR0111358
License Number StateOK
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberR0111358
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: