Basic Information
| Provider Information | |||||||||
| NPI: | 1689894297 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BOSTIC-BROWN | ||||||||
| FirstName: | MISTY | ||||||||
| MiddleName: | MECHELLE | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | BS | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 5000 SE 53RD ST | ||||||||
| Address2: | |||||||||
| City: | OKLAHOMA CITY | ||||||||
| State: | OK | ||||||||
| PostalCode: | 731354302 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4057067173 | ||||||||
| FaxNumber: | 4055257867 | ||||||||
| Practice Location | |||||||||
| Address1: | 5000 SE 53RD ST | ||||||||
| Address2: | |||||||||
| City: | OKLAHOMA CITY | ||||||||
| State: | OK | ||||||||
| PostalCode: | 731354302 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4057067173 | ||||||||
| FaxNumber: | 4055257867 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/26/2007 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251B00000X | OK | Y | Agencies | Case Management |
No ID Information.