Provider Demographics
NPI:1407129372
Name:INGRAM, STEPHENIE RENEE (CNP-FAMILY)
Entity Type:Individual
Prefix:
First Name:STEPHENIE
Middle Name:RENEE
Last Name:INGRAM
Suffix:
Gender:F
Credentials:CNP-FAMILY
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:210 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:WILBURTON
Mailing Address - State:OK
Mailing Address - Zip Code:74578-4046
Mailing Address - Country:US
Mailing Address - Phone:918-465-9612
Mailing Address - Fax:918-465-9613
Practice Address - Street 1:210 W MAIN ST
Practice Address - Street 2:
Practice Address - City:WILBURTON
Practice Address - State:OK
Practice Address - Zip Code:74578-4046
Practice Address - Country:US
Practice Address - Phone:918-465-9612
Practice Address - Fax:918-465-9613
Is Sole Proprietor?:No
Enumeration Date:2012-02-22
Last Update Date:2024-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK72256363L00000X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200426120AMedicaid