1548255599 NPI number — MRS. KIM SPROUSE CLEMENTS APRN, CNP

Table of content: MRS. KIM SPROUSE CLEMENTS APRN, CNP (NPI 1548255599)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1548255599 NPI number — MRS. KIM SPROUSE CLEMENTS APRN, CNP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CLEMENTS
Provider First Name:
KIM
Provider Middle Name:
SPROUSE
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
APRN, CNP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
SPROUSE
Provider Other First Name:
KIM
Provider Other Middle Name:
A.
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
APRN, CNP
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1548255599
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/01/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
13321 N MERIDIAN AVE
Provider Second Line Business Mailing Address:
H-MD MEDSPA
Provider Business Mailing Address City Name:
OKLAHOMA CITY
Provider Business Mailing Address State Name:
OK
Provider Business Mailing Address Postal Code:
73120-8356
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
405-463-5700
Provider Business Mailing Address Fax Number:
405-463-5705

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
13321 N MERIDIAN AVE
Provider Second Line Business Practice Location Address:
H-MD MEDSPA
Provider Business Practice Location Address City Name:
OKLAHOMA CITY
Provider Business Practice Location Address State Name:
OK
Provider Business Practice Location Address Postal Code:
73120-8356
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
405-463-5700
Provider Business Practice Location Address Fax Number:
405-463-5705
Provider Enumeration Date:
09/15/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363L00000X , with the licence number:  R0030796 , registered in the state of OK ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 30796 . This is a "STATE LICENSE" identifier , issued by the state of ( OK ) . This identifiers is of the category "OTHER".




Copyright © 2007-2024 www.npivalidator.com