Healthcare Provider Details

I. General information

NPI: 1376625228
Provider Name (Legal Business Name): MS. BRENDA ANNETTE RASMUSSEN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/19/2006
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

RR 1 BOX 28
TUPELO OK
74572-9705
US

IV. Provider business mailing address

RR 1 BOX 28
TUPELO OK
74572-9705
US

V. Phone/Fax

Practice location:
  • Phone: 580-845-2800
  • Fax:
Mailing address:
  • Phone: 580-845-2800
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code177F00000X
TaxonomyLodging Provider
License Number
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: