Provider Demographics
NPI:1437766193
Name:BURRIS-THOMAS, BRENNA GRACE
Entity Type:Individual
Prefix:
First Name:BRENNA
Middle Name:GRACE
Last Name:BURRIS-THOMAS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:BRENNA
Other - Middle Name:GRACE
Other - Last Name:BURRIS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1009 OAK CREEK DR
Mailing Address - Street 2:
Mailing Address - City:MOORE
Mailing Address - State:OK
Mailing Address - Zip Code:73160-7913
Mailing Address - Country:US
Mailing Address - Phone:580-215-8363
Mailing Address - Fax:
Practice Address - Street 1:1009 OAK CREEK DR
Practice Address - Street 2:
Practice Address - City:MOORE
Practice Address - State:OK
Practice Address - Zip Code:73160-7913
Practice Address - Country:US
Practice Address - Phone:580-215-8363
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-28
Last Update Date:2020-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program