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General NPI Number Information
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NPI Number | 1700014867
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Entity Type | Individual
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Provider Name | KENNEDY BROOKE DECKER-WALTERS ARNP
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Gender | Female
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Dates
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Enumeration Date | 06/29/2009
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Last Update Date | 03/17/2018
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Provider Practice Location Address
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Address Line | 1708 DELIVERY LANE
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City | DURANT
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State | OK
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Zip | 74701-2292
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Country | US
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Telephone | 580-924-5622
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Fax | 580-745-5060
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Provider Business Mailing Address
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Address Line | 1708 DELIVERY LANE
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City | DURANT
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State | OK
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Zip | 74701-2292
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Country | US
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Telephone | 580-924-5622
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Fax | 580-745-5060
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 163W00000X
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Taxonomy Name | Registered Nurse
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License Number | 734236
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License Number State | TX
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Taxonomy #2
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Taxonomy Code | 163W00000X
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Taxonomy Name | Registered Nurse
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License Number | 83279
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License Number State | OK
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Taxonomy #3
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Taxonomy Code | 363LF0000X
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Taxonomy Name | Family Nurse Practitioner
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License Number | R0083279
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License Number State | OK
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