Provider Demographics
NPI:1447924980
Name:ANDERSON, KELLI ANN (APRN, CNP)
Entity type:Individual
Prefix:
First Name:KELLI
Middle Name:ANN
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:APRN, CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:127 W 116TH ST
Mailing Address - Street 2:
Mailing Address - City:JENKS
Mailing Address - State:OK
Mailing Address - Zip Code:74037-3679
Mailing Address - Country:US
Mailing Address - Phone:918-605-5242
Mailing Address - Fax:
Practice Address - Street 1:8803 S 101ST EAST AVE
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74133-5726
Practice Address - Country:US
Practice Address - Phone:918-579-3270
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-08
Last Update Date:2021-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK201707363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health