Provider Demographics
NPI:1487151106
Name:BRISBIN, STEPHANI BROOKE
Entity type:Individual
Prefix:MRS
First Name:STEPHANI
Middle Name:BROOKE
Last Name:BRISBIN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:364355 E 5000 RD
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OK
Mailing Address - Zip Code:74020-6904
Mailing Address - Country:US
Mailing Address - Phone:931-436-7146
Mailing Address - Fax:
Practice Address - Street 1:2950 S ELM PL
Practice Address - Street 2:
Practice Address - City:BROKEN ARROW
Practice Address - State:OK
Practice Address - Zip Code:74012-7877
Practice Address - Country:US
Practice Address - Phone:918-451-5191
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-04-09
Last Update Date:2018-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK2857363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant