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NPI Code Detail

MEDICARE: MACKENZIE DESHAE BRUNK LPN

MEDICARE: MACKENZIE DESHAE BRUNK LPN
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1261QM0801XMental Health Clinic/Center (Including Community Mental Health Center)228794OK

General Provider Information

NPI Number : 1043144454
Entity Type Code : Individual
Provider Name (Legal Business Name) : MACKENZIE DESHAE BRUNK LPN
Provider Business Mailing Address
First Line : 711 S MUSKOGEE AVE
Second Line :
City : TAHLEQUAH
State : OK
Zip : 74464-4717
Country : US
Telephone Number : 918-207-0078
Fax Number : 918-207-0558
Provider Business Practice Location Address
First Line : 711 S MUSKOGEE AVE
Second Line :
City : TAHLEQUAH
State : OK
Zip : 74464-4717
Country : US
Telephone Number : 918-207-0078
Fax Number : 918-207-0558
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 06/10/2026
Last Update Date : 06/10/2026

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Directions to “ MACKENZIE DESHAE BRUNK LPN” Practice Location

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