Provider Demographics
NPI:1306356183
Name:DURHAM, STEPHANIE ANN (AGNP-C)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:ANN
Last Name:DURHAM
Suffix:
Gender:F
Credentials:AGNP-C
Other - Prefix:
Other - First Name:STEPHANIE
Other - Middle Name:ANN
Other - Last Name:DURHAM HOPE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:APRN CNP PMHNP
Mailing Address - Street 1:212 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:FAIRFAX
Mailing Address - State:OK
Mailing Address - Zip Code:74637-3023
Mailing Address - Country:US
Mailing Address - Phone:918-642-3100
Mailing Address - Fax:918-642-5639
Practice Address - Street 1:119 W MAIN ST
Practice Address - Street 2:
Practice Address - City:HOMINY
Practice Address - State:OK
Practice Address - Zip Code:74035-1031
Practice Address - Country:US
Practice Address - Phone:918-885-4640
Practice Address - Fax:918-885-4644
Is Sole Proprietor?:Yes
Enumeration Date:2017-10-05
Last Update Date:2023-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKAG08170142363LA2200X
OKR0064988363LP0808X
OK64988363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult HealthGroup - Multi-Specialty
No363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Multi-Specialty