Provider Demographics
NPI:1407250947
Name:PELTS, BRANDY
Entity Type:Individual
Prefix:
First Name:BRANDY
Middle Name:
Last Name:PELTS
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 1:57533 MOCCASIN TRAIL RD
Mailing Address - Street 2:
Mailing Address - City:PRAGUE
Mailing Address - State:OK
Mailing Address - Zip Code:74864-1143
Mailing Address - Country:US
Mailing Address - Phone:405-567-0054
Mailing Address - Fax:405-567-0055
Practice Address - Street 1:57533 MOCCASIN TRAIL RD
Practice Address - Street 2:
Practice Address - City:PRAGUE
Practice Address - State:OK
Practice Address - Zip Code:74864-1143
Practice Address - Country:US
Practice Address - Phone:405-567-0054
Practice Address - Fax:405-567-0055
Is Sole Proprietor?:No
Enumeration Date:2014-10-13
Last Update Date:2014-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator