Healthcare Provider Details

I. General information

NPI: 1609463587
Provider Name (Legal Business Name): JULIE VANG BROADDRICK FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/28/2020
Last Update Date: 12/28/2020
Certification Date: 12/28/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11911 S MEMORIAL DR
BIXBY OK
74008-2030
US

IV. Provider business mailing address

PO BOX 334
BIXBY OK
74008-0334
US

V. Phone/Fax

Practice location:
  • Phone: 918-943-3790
  • Fax:
Mailing address:
  • Phone: 918-943-3790
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberR0118511
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: