Provider Demographics
NPI:1568982213
Name:WILKINS, BRANDY NICOLE
Entity Type:Individual
Prefix:MRS
First Name:BRANDY
Middle Name:NICOLE
Last Name:WILKINS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:BRANDY
Other - Middle Name:NICOLE
Other - Last Name:LOWREY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:231 E GRAHAM AVE
Mailing Address - Street 2:
Mailing Address - City:PRYOR
Mailing Address - State:OK
Mailing Address - Zip Code:73361-2436
Mailing Address - Country:US
Mailing Address - Phone:918-825-1405
Mailing Address - Fax:918-825-1406
Practice Address - Street 1:231 E GRAHAM AVE
Practice Address - Street 2:
Practice Address - City:PRYOR
Practice Address - State:OK
Practice Address - Zip Code:74361-2436
Practice Address - Country:US
Practice Address - Phone:918-373-4645
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-06-23
Last Update Date:2017-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes175T00000XOther Service ProvidersPeer SpecialistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK041814764Medicaid