Provider Demographics
NPI:1831471101
Name:STEPHENS, MANDA LEA (APRN, CNP)
Entity Type:Individual
Prefix:MRS
First Name:MANDA
Middle Name:LEA
Last Name:STEPHENS
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 1:205 S. PARK LANE
Mailing Address - Street 2:
Mailing Address - City:ALTUS
Mailing Address - State:OK
Mailing Address - Zip Code:73521
Mailing Address - Country:US
Mailing Address - Phone:580-379-6650
Mailing Address - Fax:580-379-6659
Practice Address - Street 1:205 S. PARK LANE
Practice Address - Street 2:
Practice Address - City:ALTUS
Practice Address - State:OK
Practice Address - Zip Code:73521
Practice Address - Country:US
Practice Address - Phone:580-379-6650
Practice Address - Fax:580-379-6659
Is Sole Proprietor?:No
Enumeration Date:2011-09-13
Last Update Date:2024-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK66290363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health