Healthcare Provider Details

I. General information

NPI: 1336891381
Provider Name (Legal Business Name): NELSON SIMBA OGEMBO FNP-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/20/2022
Last Update Date: 10/25/2024
Certification Date: 10/24/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 WICKERSHAM ST
MANGUM OK
73554-9117
US

IV. Provider business mailing address

116 E PIERCE ST STE 500
MANGUM OK
73554-4206
US

V. Phone/Fax

Practice location:
  • Phone: 580-782-3353
  • Fax:
Mailing address:
  • Phone: 972-693-0734
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number217141
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: