Healthcare Provider Details

I. General information

NPI: 1831471101
Provider Name (Legal Business Name): MANDA LEA STEPHENS APRN, CNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/13/2011
Last Update Date: 10/30/2025
Certification Date: 10/30/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

205 S PARK LN
ALTUS OK
73521-5755
US

IV. Provider business mailing address

1200 E PECAN ST
ALTUS OK
73521-6141
US

V. Phone/Fax

Practice location:
  • Phone: 580-379-6710
  • Fax: 580-379-6714
Mailing address:
  • Phone: 580-379-5000
  • Fax: 580-379-5509

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number66290
License Number StateOK
# 2
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number66290
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: