Healthcare Provider Details

I. General information

NPI: 1538671425
Provider Name (Legal Business Name): WILBURTON FAMILY MEDICAL STEPHENIE INGRAM APRN CNP PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/31/2017
Last Update Date: 07/17/2025
Certification Date: 07/17/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

210 W MAIN ST
WILBURTON OK
74578-4046
US

IV. Provider business mailing address

210 W MAIN ST
WILBURTON OK
74578-4046
US

V. Phone/Fax

Practice location:
  • Phone: 918-465-9612
  • Fax: 918-465-9613
Mailing address:
  • Phone: 918-465-9612
  • Fax: 918-465-9613

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number
License Number StateNULL
# 3
Primary TaxonomyY
Taxonomy Code163WG0000X
TaxonomyGeneral Practice Registered Nurse
License Number72256
License Number StateOK

VIII. Authorized Official

Name: JUDY BREWSTER
Title or Position: OFFICE MANAGER
Credential:
Phone: 918-465-9612