Provider Demographics
NPI:1174891642
Name:ELLIS, KENZIE (RN,BSN,IBCLC)
Entity type:Individual
Prefix:
First Name:KENZIE
Middle Name:
Last Name:ELLIS
Suffix:
Gender:F
Credentials:RN,BSN,IBCLC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25888 S CACTUS RD
Mailing Address - Street 2:
Mailing Address - City:CLAREMORE
Mailing Address - State:OK
Mailing Address - Zip Code:74019-2372
Mailing Address - Country:US
Mailing Address - Phone:918-740-7507
Mailing Address - Fax:
Practice Address - Street 1:6161 S YALE AVE
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74136-1902
Practice Address - Country:US
Practice Address - Phone:918-494-2200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-12-12
Last Update Date:2011-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK8841163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse