Provider Demographics
NPI:1366153496
Name:SHUPERT, ANGELA M (RN)
Entity type:Individual
Prefix:
First Name:ANGELA
Middle Name:M
Last Name:SHUPERT
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20361 PINE MTN LOOP
Mailing Address - Street 2:
Mailing Address - City:HEAVENER
Mailing Address - State:OK
Mailing Address - Zip Code:74937-3679
Mailing Address - Country:US
Mailing Address - Phone:918-658-4149
Mailing Address - Fax:
Practice Address - Street 1:511 E 2ND ST
Practice Address - Street 2:
Practice Address - City:HEAVENER
Practice Address - State:OK
Practice Address - Zip Code:74937-3419
Practice Address - Country:US
Practice Address - Phone:918-653-7718
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-12-09
Last Update Date:2022-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK0112203163WP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental Health