Healthcare Provider Details

I. General information

NPI: 1528539475
Provider Name (Legal Business Name): ANGEL MARIE ALLEN APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: ANGEL MARIE BRULAR

II. Dates (important events)

Enumeration Date: 12/17/2018
Last Update Date: 06/09/2021
Certification Date: 06/09/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1705 E 19TH ST STE 502
TULSA OK
74104-5416
US

IV. Provider business mailing address

1705 E 19TH ST STE 502
TULSA OK
74104-5416
US

V. Phone/Fax

Practice location:
  • Phone: 918-748-7800
  • Fax: 918-403-6349
Mailing address:
  • Phone: 918-748-7800
  • Fax: 918-403-6349

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number80252
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: