Provider Demographics
NPI:1679598809
Name:KMITA, KIMBERELY DAWN (CNM, ARNP)
Entity type:Individual
Prefix:MRS
First Name:KIMBERELY
Middle Name:DAWN
Last Name:KMITA
Suffix:
Gender:F
Credentials:CNM, ARNP
Other - Prefix:MS
Other - First Name:KIMBERELY
Other - Middle Name:D
Other - Last Name:MURRY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CNM, ARNP
Mailing Address - Street 1:8803 S 101ST EAST AVE
Mailing Address - Street 2:STE 205
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74133-5730
Mailing Address - Country:US
Mailing Address - Phone:918-858-0008
Mailing Address - Fax:918-858-0074
Practice Address - Street 1:1120 S UTICA AVE
Practice Address - Street 2:STE. G100
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74104-4012
Practice Address - Country:US
Practice Address - Phone:918-392-0175
Practice Address - Fax:918-392-0176
Is Sole Proprietor?:No
Enumeration Date:2006-07-12
Last Update Date:2017-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKR0066134367A00000X
OK66134363LW0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
No363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200064280AMedicaid
OK1679598809OtherNPI #
OK200064280AMedicaid
OK1679598809OtherNPI #