MEDICARE: MRS. KELLY MARIE WILLIAMSON FNP

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	210924	OK

General Provider Information

NPI Number	:	1770294886
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. KELLY MARIE WILLIAMSON FNP

Provider Business Mailing Address
First Line	:	10462 S 82ND EAST AVE STE 107
Second Line	:
City	:	TULSA
State	:	OK
Zip	:	74133-7090
Country	:	US
Telephone Number	:	918-364-5698
Fax Number	:

Provider Business Practice Location Address
First Line	:	10462 S 82ND EAST AVE
Second Line	:
City	:	TULSA
State	:	OK
Zip	:	74133-7089
Country	:	US
Telephone Number	:	918-364-5698
Fax Number	:

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

Provider Enumeration Date	:	12/09/2022
Last Update Date	:	12/09/2022

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