Healthcare Provider Details

I. General information

NPI: 1326969825
Provider Name (Legal Business Name): NANA FAJUGBAGBE FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/22/2026
Last Update Date: 07/22/2026
Certification Date: 07/04/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1216 E KENOSHA ST # 320
BROKEN ARROW OK
74012-2007
US

IV. Provider business mailing address

10218 S 229TH EAST AVE
BROKEN ARROW OK
74014-6268
US

V. Phone/Fax

Practice location:
  • Phone: 918-744-3131
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number209705
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: