Healthcare Provider Details

I. General information

NPI: 1164706305
Provider Name (Legal Business Name): TAMMIE BRADY
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/06/2011
Last Update Date: 10/06/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

27753 S WELLING RD
WELLING OK
74471-2202
US

IV. Provider business mailing address

PO BOX 580
STILWELL OK
74960-0580
US

V. Phone/Fax

Practice location:
  • Phone: 918-456-1010
  • Fax: 918-457-5540
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: