Provider Demographics
NPI:1194723239
Name:EDDY, KETTI LYNN (APRN-CNP)
Entity type:Individual
Prefix:
First Name:KETTI
Middle Name:LYNN
Last Name:EDDY
Suffix:
Gender:F
Credentials:APRN-CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1603 HUNTERS PATH
Mailing Address - Street 2:
Mailing Address - City:EDMOND
Mailing Address - State:OK
Mailing Address - Zip Code:73034-1627
Mailing Address - Country:US
Mailing Address - Phone:405-919-7570
Mailing Address - Fax:405-256-9748
Practice Address - Street 1:105 E INDUSTRIAL RD STE B
Practice Address - Street 2:
Practice Address - City:GUTHRIE
Practice Address - State:OK
Practice Address - Zip Code:73044-6971
Practice Address - Country:US
Practice Address - Phone:405-919-7570
Practice Address - Fax:405-256-9748
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-12
Last Update Date:2021-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKR0074528363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200057880AMedicaid
OKQ49623Medicare UPIN
OK244523608Medicare PIN