Provider Demographics
NPI:1174262646
Name:EDENBOROUGH, BREANNA ROCHELLE (PT)
Entity Type:Individual
Prefix:
First Name:BREANNA
Middle Name:ROCHELLE
Last Name:EDENBOROUGH
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4651 N HARRISON ST
Mailing Address - Street 2:
Mailing Address - City:SHAWNEE
Mailing Address - State:OK
Mailing Address - Zip Code:74804-1440
Mailing Address - Country:US
Mailing Address - Phone:405-214-1524
Mailing Address - Fax:405-395-5653
Practice Address - Street 1:4651 N HARRISON ST
Practice Address - Street 2:
Practice Address - City:SHAWNEE
Practice Address - State:OK
Practice Address - Zip Code:74804-1440
Practice Address - Country:US
Practice Address - Phone:405-214-1524
Practice Address - Fax:405-395-5653
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-02
Last Update Date:2022-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK5327225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist