Provider Demographics
NPI:1235481771
Name:VANDIVER, KATHERYN NOEL (APRN)
Entity type:Individual
Prefix:
First Name:KATHERYN
Middle Name:NOEL
Last Name:VANDIVER
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:KATHERYN
Other - Middle Name:NOEL
Other - Last Name:KENEMER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:APRN
Mailing Address - Street 1:2100 SW 119TH ST
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73170-3437
Mailing Address - Country:US
Mailing Address - Phone:405-691-1041
Mailing Address - Fax:405-378-3480
Practice Address - Street 1:2100 SW 119TH ST
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73170-3437
Practice Address - Country:US
Practice Address - Phone:405-691-1041
Practice Address - Fax:405-378-3480
Is Sole Proprietor?:Yes
Enumeration Date:2012-10-08
Last Update Date:2021-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK88767363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily