=====================================================
General NPI Number Information
=====================================================
NPI Number | 1124582879
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KELLY FINNERTY FNP
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/28/2019
-----------------------------------------------------
Last Update Date | 03/25/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4 E CLARK BASS BLVD STE 301
-----------------------------------------------------
City | MCALESTER
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 74501-4269
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 918-421-4673
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 1992
-----------------------------------------------------
City | MCALESTER
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 74502-1992
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 918-426-2442
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363L00000X
-----------------------------------------------------
Taxonomy Name | Nurse Practitioner
-----------------------------------------------------
License Number | M113586
-----------------------------------------------------
License Number State | OK
-----------------------------------------------------