Provider Demographics
NPI:1174893069
Name:BRANNON, TINA MARGARET (LPN, BS)
Entity type:Individual
Prefix:
First Name:TINA
Middle Name:MARGARET
Last Name:BRANNON
Suffix:
Gender:F
Credentials:LPN, BS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1201 W WILSHIRE BLVD
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73116-6108
Mailing Address - Country:US
Mailing Address - Phone:405-209-6862
Mailing Address - Fax:
Practice Address - Street 1:1201 W WILSHIRE BLVD
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73116-6108
Practice Address - Country:US
Practice Address - Phone:405-209-6862
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-01-09
Last Update Date:2012-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKL OO17786101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK453004024OtherLPN L 0017786