Healthcare Provider Details

I. General information

NPI: 1306356183
Provider Name (Legal Business Name): STEPHANIE ANN DURHAM AGNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: STEPHANIE ANN DURHAM HOPE APRN CNP PMHNP

II. Dates (important events)

Enumeration Date: 10/05/2017
Last Update Date: 10/28/2023
Certification Date: 10/28/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

119 W MAIN ST
HOMINY OK
74035-1031
US

IV. Provider business mailing address

212 N MAIN ST
FAIRFAX OK
74637-3023
US

V. Phone/Fax

Practice location:
  • Phone: 918-885-4640
  • Fax: 918-885-4644
Mailing address:
  • Phone: 918-642-3100
  • Fax: 918-642-5639

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License NumberAG08170142
License Number StateOK
# 2
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberR0064988
License Number StateOK
# 3
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number64988
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: