MEDICARE: KATHERYN NOEL VANDIVER APRN

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	363LF0000X	Family Nurse Practitioner	88767	OK

General Provider Information

NPI Number	:	1235481771
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KATHERYN NOEL VANDIVER APRN

Provider Business Mailing Address
First Line	:	2100 SW 119TH ST
Second Line	:
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73170-3437
Country	:	US
Telephone Number	:	405-691-1041
Fax Number	:	405-378-3480

Provider Business Practice Location Address
First Line	:	2100 SW 119TH ST
Second Line	:
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73170-3437
Country	:	US
Telephone Number	:	405-691-1041
Fax Number	:	405-378-3480

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

Provider Enumeration Date	:	10/08/2012
Last Update Date	:	06/30/2021

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