Provider Demographics
NPI:1407471402
Name:WILSON, BRENDA JUNE (APRN NP-C)
Entity Type:Individual
Prefix:
First Name:BRENDA
Middle Name:JUNE
Last Name:WILSON
Suffix:
Gender:F
Credentials:APRN NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8609 SW 58TH CIR
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73179-7910
Mailing Address - Country:US
Mailing Address - Phone:405-543-7994
Mailing Address - Fax:
Practice Address - Street 1:2307 GORDON COOPER DR
Practice Address - Street 2:
Practice Address - City:SHAWNEE
Practice Address - State:OK
Practice Address - Zip Code:74801-9007
Practice Address - Country:US
Practice Address - Phone:405-273-5236
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-06-15
Last Update Date:2021-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK101889363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner