Provider Demographics
NPI:1548255599
Name:CLEMENTS, KIM SPROUSE (APRN, CNP)
Entity type:Individual
Prefix:MRS
First Name:KIM
Middle Name:SPROUSE
Last Name:CLEMENTS
Suffix:
Gender:F
Credentials:APRN, CNP
Other - Prefix:
Other - First Name:KIM
Other - Middle Name:A
Other - Last Name:SPROUSE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:APRN, CNP
Mailing Address - Street 1:13321 N MERIDIAN AVE
Mailing Address - Street 2:H-MD MEDSPA
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73120-8356
Mailing Address - Country:US
Mailing Address - Phone:405-463-5700
Mailing Address - Fax:405-463-5705
Practice Address - Street 1:13321 N MERIDIAN AVE
Practice Address - Street 2:H-MD MEDSPA
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73120-8356
Practice Address - Country:US
Practice Address - Phone:405-463-5700
Practice Address - Fax:405-463-5705
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-15
Last Update Date:2014-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKR0030796363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK30796OtherSTATE LICENSE
OK30796OtherSTATE LICENSE
OK30796OtherSTATE LICENSE