Provider Demographics
NPI:1982611273
Name:STEPHENSON, IDA REBECCA (CNM)
Entity Type:Individual
Prefix:
First Name:IDA
Middle Name:REBECCA
Last Name:STEPHENSON
Suffix:
Gender:F
Credentials:CNM
Other - Prefix:
Other - First Name:IDA
Other - Middle Name:ELLIS
Other - Last Name:STEPHENSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CNM
Mailing Address - Street 1:100 S BLISS AVE
Mailing Address - Street 2:
Mailing Address - City:TAHLEQUAH
Mailing Address - State:OK
Mailing Address - Zip Code:74464-2512
Mailing Address - Country:US
Mailing Address - Phone:918-458-3100
Mailing Address - Fax:918-458-3511
Practice Address - Street 1:100 S BLISS AVE
Practice Address - Street 2:
Practice Address - City:TAHLEQUAH
Practice Address - State:OK
Practice Address - Zip Code:74464-2512
Practice Address - Country:US
Practice Address - Phone:918-458-3100
Practice Address - Fax:918-458-3511
Is Sole Proprietor?:No
Enumeration Date:2006-08-01
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK33496367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
OKP47411Medicare UPIN
OK8HZA92Medicare ID - Type UnspecifiedMEDICARE PROVIDER #- WWH