Healthcare Provider Details

I. General information

NPI: 1215873930
Provider Name (Legal Business Name): BRIANNA NICOLE MACK
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/25/2026
Last Update Date: 04/25/2026
Certification Date: 04/25/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

700 NE 13TH ST
OKLAHOMA CITY OK
73104-5004
US

IV. Provider business mailing address

4800 E I 240 SERVICE RD APT 1623
OKLAHOMA CITY OK
73135-2634
US

V. Phone/Fax

Practice location:
  • Phone: 405-271-4700
  • Fax:
Mailing address:
  • Phone: 682-553-9518
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: