Healthcare Provider Details

I. General information

NPI: 1083524615
Provider Name (Legal Business Name): BRENDA JOHNSON C-CHW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/08/2026
Last Update Date: 09/08/2026
Certification Date: 09/04/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

29 HOSPITAL DR.
EUFAULA OK
74432
US

IV. Provider business mailing address

325 LONDON DOCK LN
CANADIAN OK
74425-5132
US

V. Phone/Fax

Practice location:
  • Phone: 918-689-7774
  • Fax:
Mailing address:
  • Phone: 405-365-4885
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number202520
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: