Provider Demographics
NPI:1679015416
Name:FORTEH, MIRABEL (APRN-CNP)
Entity Type:Individual
Prefix:
First Name:MIRABEL
Middle Name:
Last Name:FORTEH
Suffix:
Gender:F
Credentials:APRN-CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1921 N SKYLINE ST
Mailing Address - Street 2:
Mailing Address - City:STILLWATER
Mailing Address - State:OK
Mailing Address - Zip Code:74075-3102
Mailing Address - Country:US
Mailing Address - Phone:405-533-3010
Mailing Address - Fax:
Practice Address - Street 1:1301 W 6TH AVE STE 207
Practice Address - Street 2:
Practice Address - City:STILLWATER
Practice Address - State:OK
Practice Address - Zip Code:74074-4381
Practice Address - Country:US
Practice Address - Phone:405-533-3010
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-11-10
Last Update Date:2016-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK100187363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner