Provider Demographics
NPI:1275284028
Name:VERMILLION, BRANDY JO (APRN-CNP)
Entity Type:Individual
Prefix:
First Name:BRANDY
Middle Name:JO
Last Name:VERMILLION
Suffix:
Gender:F
Credentials:APRN-CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1200 E PECAN ST
Mailing Address - Street 2:
Mailing Address - City:ALTUS
Mailing Address - State:OK
Mailing Address - Zip Code:73521-6141
Mailing Address - Country:US
Mailing Address - Phone:580-379-5000
Mailing Address - Fax:580-379-5509
Practice Address - Street 1:114 S LOUIS TITTLE AVE
Practice Address - Street 2:
Practice Address - City:MANGUM
Practice Address - State:OK
Practice Address - Zip Code:73554-4406
Practice Address - Country:US
Practice Address - Phone:580-782-3393
Practice Address - Fax:580-782-3395
Is Sole Proprietor?:No
Enumeration Date:2022-01-13
Last Update Date:2022-09-27
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
OK206477363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK201045540AMedicaid