Healthcare Provider Details

I. General information

NPI: 1265985717
Provider Name (Legal Business Name): SHANNON BRUEY
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/02/2016
Last Update Date: 09/11/2025
Certification Date: 09/11/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1202 W FARM RD
STILLWATER OK
74078-2000
US

IV. Provider business mailing address

1202 W FARM RD
STILLWATER OK
74078-2000
US

V. Phone/Fax

Practice location:
  • Phone: 405-744-7665
  • Fax: 405-744-6556
Mailing address:
  • Phone: 405-744-7665
  • Fax: 405-744-6556

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberR0096735
License Number StateOK
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number96735
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: