Provider Demographics
NPI:1811267891
Name:VIBRANT HEALTH APRN PC
Entity type:Organization
Organization Name:VIBRANT HEALTH APRN PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:P
Authorized Official - Last Name:WARREN
Authorized Official - Suffix:
Authorized Official - Credentials:APRN
Authorized Official - Phone:918-591-3567
Mailing Address - Street 1:2121 S COLUMBIA AVE
Mailing Address - Street 2:STE 300
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74114-3501
Mailing Address - Country:US
Mailing Address - Phone:918-591-3567
Mailing Address - Fax:
Practice Address - Street 1:1822 E 15TH ST STE A
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74104-4647
Practice Address - Country:US
Practice Address - Phone:918-591-3567
Practice Address - Fax:918-591-3568
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-01-06
Last Update Date:2019-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK50761363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200413230AMedicaid
OK100198180AMedicaid