MEDICARE: ANDREA KINKEADE

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	390200000X	Student in an Organized Health Care Education/Training Program

General Provider Information

NPI Number	:	1184165557
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ANDREA KINKEADE

Provider Business Mailing Address
First Line	:	521 E FORT WORTH DR
Second Line	:
City	:	BROKEN ARROW
State	:	OK
Zip	:	74012-4314
Country	:	US
Telephone Number	:	918-574-1004
Fax Number	:

Provider Business Practice Location Address
First Line	:	521 E FORT WORTH DR
Second Line	:
City	:	BROKEN ARROW
State	:	OK
Zip	:	74012-4314
Country	:	US
Telephone Number	:	918-574-1004
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/17/2017
Last Update Date	:	03/17/2017

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