Provider Demographics
NPI:1154873743
Name:STURDIVANT, MICHELLE RENEE (NP)
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:RENEE
Last Name:STURDIVANT
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:616 SW 6TH ST
Mailing Address - Street 2:
Mailing Address - City:MOORE
Mailing Address - State:OK
Mailing Address - Zip Code:73160-2511
Mailing Address - Country:US
Mailing Address - Phone:405-595-6969
Mailing Address - Fax:
Practice Address - Street 1:616 SW 6TH ST
Practice Address - Street 2:
Practice Address - City:MOORE
Practice Address - State:OK
Practice Address - Zip Code:73160-2511
Practice Address - Country:US
Practice Address - Phone:405-595-6969
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-10-29
Last Update Date:2024-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKR0100094363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200791020AMedicaid
OKR0100094OtherLICENSE