=====================================================
General NPI Number Information
=====================================================
NPI Number | 1699305870
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SUSAN WANGARI KIBE APRN
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/16/2020
-----------------------------------------------------
Last Update Date | 05/13/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 625 N MONTE VISTA ST
-----------------------------------------------------
City | ADA
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 74820-4613
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 580-436-5111
-----------------------------------------------------
Fax | 580-436-1159
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 527 W 3RD ST
-----------------------------------------------------
City | KONAWA
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 74849-1415
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 580-925-3286
-----------------------------------------------------
Fax | 580-925-2362
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 163W00000X
-----------------------------------------------------
Taxonomy Name | Registered Nurse
-----------------------------------------------------
License Number | 912132
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 363LP0808X
-----------------------------------------------------
Taxonomy Name | Psychiatric/Mental Health Nurse Practitioner
-----------------------------------------------------
License Number | 215675
-----------------------------------------------------
License Number State | OK
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 363L00000X
-----------------------------------------------------
Taxonomy Name | Nurse Practitioner
-----------------------------------------------------
License Number | 215675
-----------------------------------------------------
License Number State | OK
-----------------------------------------------------