=====================================================
General NPI Number Information
=====================================================
NPI Number | 1225723760
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | AUDREY DEANNE KINCANNON
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/10/2023
-----------------------------------------------------
Last Update Date | 05/12/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1116 19TH ST
-----------------------------------------------------
City | WOODWARD
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 73801-2925
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 580-922-5656
-----------------------------------------------------
Fax | 580-922-3261
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 177
-----------------------------------------------------
City | SEILING
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 73663-0177
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 580-922-5656
-----------------------------------------------------
Fax | 580-922-3261
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 171M00000X
-----------------------------------------------------
Taxonomy Name | Case Manager/Care Coordinator
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------