Provider Demographics
NPI:1447409206
Name:ELLIS, KERRI LEE (ARNP)
Entity type:Individual
Prefix:MRS
First Name:KERRI
Middle Name:LEE
Last Name:ELLIS
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 478
Mailing Address - Street 2:103 E MAIN ST
Mailing Address - City:BEGGS
Mailing Address - State:OK
Mailing Address - Zip Code:74421-0478
Mailing Address - Country:US
Mailing Address - Phone:918-367-0010
Mailing Address - Fax:918-703-4713
Practice Address - Street 1:103 E MAIN ST
Practice Address - Street 2:
Practice Address - City:BEGGS
Practice Address - State:OK
Practice Address - Zip Code:74421
Practice Address - Country:US
Practice Address - Phone:918-267-7000
Practice Address - Fax:918-267-7077
Is Sole Proprietor?:Yes
Enumeration Date:2008-09-16
Last Update Date:2021-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK53535363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100708410BMedicaid