1871891861 NPI number — WANDA KAYE BRAZEAL FPMHNP

Table of content: WANDA KAYE BRAZEAL FPMHNP (NPI 1871891861)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1871891861 NPI number — WANDA KAYE BRAZEAL FPMHNP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BRAZEAL
Provider First Name:
WANDA
Provider Middle Name:
KAYE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
FPMHNP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1871891861
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/28/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 21228
Provider Second Line Business Mailing Address:
DEPARTMENT 31
Provider Business Mailing Address City Name:
TULSA
Provider Business Mailing Address State Name:
OK
Provider Business Mailing Address Postal Code:
74121-1228
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
918-491-3700
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6655 S YALE AVE
Provider Second Line Business Practice Location Address:
LAUREATE PSYCHIATRIC CLINIC AND HOSPITAL
Provider Business Practice Location Address City Name:
TULSA
Provider Business Practice Location Address State Name:
OK
Provider Business Practice Location Address Postal Code:
74136-3326
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
918-491-3700
Provider Business Practice Location Address Fax Number:
918-491-5740
Provider Enumeration Date:
03/01/2011

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363LP0808X , with the licence number:  72748 , registered in the state of OK ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 200329080A , issued by the state of ( OK ) . This identifiers is of the category "MEDICAID".




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