Healthcare Provider Details

I. General information

NPI: 1093610339
Provider Name (Legal Business Name): SHANNON BRUEY PMHMP LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/08/2026
Last Update Date: 10/08/2026
Certification Date: 10/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1750 W LAKEVIEW RD
STILLWATER OK
74075-2746
US

IV. Provider business mailing address

1750 W LAKEVIEW RD
STILLWATER OK
74075-2746
US

V. Phone/Fax

Practice location:
  • Phone: 405-984-4802
  • Fax: 405-984-4819
Mailing address:
  • Phone: 405-984-4802
  • Fax: 405-984-4819

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number
License Number StateNULL

VIII. Authorized Official

Name: SHANNON BRUEY
Title or Position: SOLE MEMBER
Credential: PMHNP-BC, APRN-CNP
Phone: 405-984-4802