Basic Information
| Provider Information | |||||||||
| NPI: | 1164420501 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KITE | ||||||||
| FirstName: | CHERYL | ||||||||
| MiddleName: | ANN | ||||||||
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| Credential: | ANP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5002 COWHORN CREEK RD | ||||||||
| Address2: | |||||||||
| City: | TEXARKANA | ||||||||
| State: | TX | ||||||||
| PostalCode: | 755039766 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9036143000 | ||||||||
| FaxNumber: | 9036143525 | ||||||||
| Practice Location | |||||||||
| Address1: | 5002 COWHORN CREEK RD | ||||||||
| Address2: | |||||||||
| City: | TEXARKANA | ||||||||
| State: | TX | ||||||||
| PostalCode: | 75503 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9036143000 | ||||||||
| FaxNumber: | 9036143525 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/11/2005 | ||||||||
| LastUpdateDate: | 06/11/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | AO1521 | AR | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 363L00000X | 691578 | TX | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | 143581758 | 01 | AK | MEDICAID | OTHER | 144772402 | 05 | TX | MEDICAID |