Provider Demographics
NPI:1366080830
Name:BRECKENRIDGE, KIMMY RENEA (LPN)
Entity type:Individual
Prefix:
First Name:KIMMY
Middle Name:RENEA
Last Name:BRECKENRIDGE
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5304 SW TYLER AVE
Mailing Address - Street 2:
Mailing Address - City:LAWTON
Mailing Address - State:OK
Mailing Address - Zip Code:73505-5750
Mailing Address - Country:US
Mailing Address - Phone:580-351-8520
Mailing Address - Fax:
Practice Address - Street 1:5304 SW TYLER AVE
Practice Address - Street 2:
Practice Address - City:LAWTON
Practice Address - State:OK
Practice Address - Zip Code:73505-5750
Practice Address - Country:US
Practice Address - Phone:580-351-8520
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-12-16
Last Update Date:2019-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK70881164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse