Healthcare Provider Details

I. General information

NPI: 1912381526
Provider Name (Legal Business Name): BRYAN KIENTZ
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/13/2015
Last Update Date: 07/13/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7651 S 305TH EAST AVE
BROKEN ARROW OK
74014-6020
US

IV. Provider business mailing address

7651 S 305TH EAST AVE
BROKEN ARROW OK
74014-6020
US

V. Phone/Fax

Practice location:
  • Phone: 918-810-5351
  • Fax:
Mailing address:
  • Phone: 918-810-5351
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number62244
License Number StateOK
# 2
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number62244
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: