Healthcare Provider Details

I. General information

NPI: 1396675740
Provider Name (Legal Business Name): BRANDON AMBROSE KEMP
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/19/2026
Last Update Date: 05/19/2026
Certification Date: 05/19/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

800 STANTON L YOUNG BLVD
OKLAHOMA CITY OK
73104-5018
US

IV. Provider business mailing address

1033 NE 4TH ST APT F418
OKLAHOMA CITY OK
73117-2438
US

V. Phone/Fax

Practice location:
  • Phone: 405-271-2316
  • Fax:
Mailing address:
  • Phone: 434-409-3377
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: