Healthcare Provider Details

I. General information

NPI: 1548222532
Provider Name (Legal Business Name): BRANDIE JO THORNTON NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/05/2006
Last Update Date: 03/02/2022
Certification Date: 03/02/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1831 E 71ST ST
TULSA OK
74136-3922
US

IV. Provider business mailing address

PO BOX 9178
RUSSELLVILLE AR
72811-9178
US

V. Phone/Fax

Practice location:
  • Phone: 855-498-6767
  • Fax: 479-968-1673
Mailing address:
  • Phone: 855-498-6767
  • Fax: 479-968-1673

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number204793
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: