MEDICARE: BREENE AUDREY LYNN MCMILLAN LMT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225700000X	Massage Therapist	197844	OK

General Provider Information

NPI Number	:	1700642188
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BREENE AUDREY LYNN MCMILLAN LMT

Provider Business Mailing Address
First Line	:	1200 KELLY PARK RD
Second Line	:
City	:	EDMOND
State	:	OK
Zip	:	73003-5850
Country	:	US
Telephone Number	:	405-441-5641
Fax Number	:

Provider Business Practice Location Address
First Line	:	5300 N MERIDIAN AVE STE 6
Second Line	:
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73112-2137
Country	:	US
Telephone Number	:	405-441-5641
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/23/2024
Last Update Date	:	02/23/2024

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