Provider Demographics
NPI:1336891381
Name:OGEMBO, NELSON SIMBA (FNP-C)
Entity type:Individual
Prefix:
First Name:NELSON
Middle Name:SIMBA
Last Name:OGEMBO
Suffix:
Gender:M
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:116 E PIERCE ST STE 500
Mailing Address - Street 2:
Mailing Address - City:MANGUM
Mailing Address - State:OK
Mailing Address - Zip Code:73554-4206
Mailing Address - Country:US
Mailing Address - Phone:972-693-0734
Mailing Address - Fax:
Practice Address - Street 1:1 WICKERSHAM ST
Practice Address - Street 2:
Practice Address - City:MANGUM
Practice Address - State:OK
Practice Address - Zip Code:73554-9117
Practice Address - Country:US
Practice Address - Phone:580-782-3353
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-01-20
Last Update Date:2024-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK217141363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK217141OtherOKLAHOMA BOARD OF NURSING
OK201250440AMedicaid