Provider Demographics
NPI:1134351141
Name:COBB, KIMBERLY KAY (ARNP)
Entity type:Individual
Prefix:MRS
First Name:KIMBERLY
Middle Name:KAY
Last Name:COBB
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 582
Mailing Address - Street 2:
Mailing Address - City:POTEAU
Mailing Address - State:OK
Mailing Address - Zip Code:74953-0582
Mailing Address - Country:US
Mailing Address - Phone:918-649-0069
Mailing Address - Fax:918-649-0067
Practice Address - Street 1:210 W ROBERT ST
Practice Address - Street 2:
Practice Address - City:POTEAU
Practice Address - State:OK
Practice Address - Zip Code:74953
Practice Address - Country:US
Practice Address - Phone:918-649-0069
Practice Address - Fax:918-649-0067
Is Sole Proprietor?:No
Enumeration Date:2009-08-10
Last Update Date:2018-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARA03297363LF0000X
OK66821363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200255520BMedicaid
OKOKA106061Medicare PIN