Provider Demographics
NPI:1104522697
Name:OSBORN, ANGIE (PMHNP-BC)
Entity type:Individual
Prefix:
First Name:ANGIE
Middle Name:
Last Name:OSBORN
Suffix:
Gender:F
Credentials:PMHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1501 S RANCHWOOD BLVD STE 203
Mailing Address - Street 2:
Mailing Address - City:YUKON
Mailing Address - State:OK
Mailing Address - Zip Code:73099-2758
Mailing Address - Country:US
Mailing Address - Phone:405-914-6634
Mailing Address - Fax:405-914-6693
Practice Address - Street 1:1501 S RANCHWOOD BLVD STE 203
Practice Address - Street 2:
Practice Address - City:YUKON
Practice Address - State:OK
Practice Address - Zip Code:73099-2758
Practice Address - Country:US
Practice Address - Phone:405-914-6634
Practice Address - Fax:405-914-6693
Is Sole Proprietor?:No
Enumeration Date:2023-02-06
Last Update Date:2025-02-13
Deactivation Date:2024-11-19
Deactivation Code:
Reactivation Date:2024-11-25
Provider Licenses
StateLicense IDTaxonomies
OK211056363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health