Provider Demographics
NPI:1548222532
Name:THORNTON, BRANDIE JO (NP)
Entity Type:Individual
Prefix:
First Name:BRANDIE
Middle Name:JO
Last Name:THORNTON
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 9178
Mailing Address - Street 2:
Mailing Address - City:RUSSELLVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72811-9178
Mailing Address - Country:US
Mailing Address - Phone:855-498-6767
Mailing Address - Fax:479-968-1673
Practice Address - Street 1:1831 E 71ST ST
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74136-3922
Practice Address - Country:US
Practice Address - Phone:855-498-6767
Practice Address - Fax:479-968-1673
Is Sole Proprietor?:No
Enumeration Date:2006-04-05
Last Update Date:2022-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK204793363LF0000X
CANP20109363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8N9007OtherBLUE SHIELD
TX1754103-02Medicaid
TX1754103-02Medicaid
TX8G0348Medicare ID - Type Unspecified