Provider Demographics
NPI:1144077553
Name:SCAGGS, KIMBERLY MICHELL (AGACNP)
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:MICHELL
Last Name:SCAGGS
Suffix:
Gender:F
Credentials:AGACNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5630 TRIPLE L RD
Mailing Address - Street 2:
Mailing Address - City:DAVIS
Mailing Address - State:OK
Mailing Address - Zip Code:73030-9486
Mailing Address - Country:US
Mailing Address - Phone:580-618-2413
Mailing Address - Fax:
Practice Address - Street 1:430 N MONTE VISTA ST
Practice Address - Street 2:
Practice Address - City:ADA
Practice Address - State:OK
Practice Address - Zip Code:74820-4657
Practice Address - Country:US
Practice Address - Phone:580-332-2323
Practice Address - Fax:580-421-1384
Is Sole Proprietor?:Yes
Enumeration Date:2024-05-02
Last Update Date:2024-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK217660363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute CareGroup - Single Specialty