Healthcare Provider Details

I. General information

NPI: 1508415092
Provider Name (Legal Business Name): ANGELA ANNETTE COLBORN APRN, NP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/06/2019
Last Update Date: 10/01/2020
Certification Date: 10/01/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

535 6TH ST
PAWNEE OK
74058-2542
US

IV. Provider business mailing address

119 RANDOLPH CT
STILLWATER OK
74075-3841
US

V. Phone/Fax

Practice location:
  • Phone: 918-762-3942
  • Fax:
Mailing address:
  • Phone: 970-629-1364
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number68417
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: