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General NPI Number Information
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NPI Number | 1245986629
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Entity Type | Individual
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Provider Name | MS. MAGGIE LYNN PEMBROOK
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Gender | Female
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Dates
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Enumeration Date | 02/24/2022
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Last Update Date | 09/01/2022
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Provider Practice Location Address
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Address Line | 102 N DENVER AVE
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City | TULSA
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State | OK
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Zip | 74103-1806
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Country | US
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Telephone | 918-582-1200
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Fax | 918-560-1399
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Provider Business Mailing Address
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Address Line | 2705 S BEECH AVE
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City | BROKEN ARROW
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State | OK
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Zip | 74012-7306
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Country | US
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Telephone | 918-645-8262
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 171M00000X
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Taxonomy Name | Case Manager/Care Coordinator
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 390200000X
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Taxonomy Name | Student in an Organized Health Care Education/Training Program
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License Number |
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License Number State |
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