Basic Information
| Provider Information | |||||||||
| NPI: | 1679217624 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DAVIS | ||||||||
| FirstName: | BRANDIE | ||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 1900 W BROADWAY AVE APT 58 | ||||||||
| Address2: | |||||||||
| City: | ELK CITY | ||||||||
| State: | OK | ||||||||
| PostalCode: | 736445154 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5802100933 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 3080 W 3RD ST | ||||||||
| Address2: | |||||||||
| City: | ELK CITY | ||||||||
| State: | OK | ||||||||
| PostalCode: | 736444323 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4054247711 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/26/2022 | ||||||||
| LastUpdateDate: | 04/26/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 04/26/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 171400000X | Y |
No ID Information.