Provider Demographics
NPI:1538671425
Name:WILBURTON FAMILY MEDICAL STEPHENIE INGRAM APRN CNP PLLC
Entity Type:Organization
Organization Name:WILBURTON FAMILY MEDICAL STEPHENIE INGRAM APRN CNP PLLC
Other - Org Name:WILBURTON FAMILY MEDICAL
Other - Org Type:Other Name
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JUDY
Authorized Official - Middle Name:
Authorized Official - Last Name:BREWSTER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:918-465-9612
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
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-10-31
Last Update Date:2020-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK72256163WG0000X
261Q00000X, 261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes163WG0000XNursing Service ProvidersRegistered NurseGeneral PracticeGroup - Single Specialty
No261Q00000XAmbulatory Health Care FacilitiesClinic/CenterGroup - Single Specialty
No261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary CareGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200426120AMedicaid