MEDICARE: BRANDY MICHELLE MUSGROVE

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
1	175T00000X	Peer Specialist

General Provider Information

NPI Number	:	1558993519
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BRANDY MICHELLE MUSGROVE

Provider Business Mailing Address
First Line	:	2225 N UNION ST
Second Line	:
City	:	PONCA CITY
State	:	OK
Zip	:	74601-1536
Country	:	US
Telephone Number	:	580-749-5056
Fax Number	:	580-215-5765

Provider Business Practice Location Address
First Line	:	2225 N UNION ST
Second Line	:
City	:	PONCA CITY
State	:	OK
Zip	:	74601-1536
Country	:	US
Telephone Number	:	580-749-5056
Fax Number	:	580-215-5765

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/07/2020
Last Update Date	:	03/11/2020

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Directions to “ BRANDY MICHELLE MUSGROVE ” Practice Location

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