Provider Demographics
NPI:1598347288
Name:SHANNON BRUEY PMHMP LLC
Entity Type:Organization
Organization Name:SHANNON BRUEY PMHMP LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PROVIDER
Authorized Official - Prefix:
Authorized Official - First Name:SHANNON
Authorized Official - Middle Name:
Authorized Official - Last Name:BRUEY
Authorized Official - Suffix:
Authorized Official - Credentials:PMHMP
Authorized Official - Phone:580-984-1115
Mailing Address - Street 1:121 W MAPLE AVE
Mailing Address - Street 2:
Mailing Address - City:ENID
Mailing Address - State:OK
Mailing Address - Zip Code:73701-4027
Mailing Address - Country:US
Mailing Address - Phone:580-984-1115
Mailing Address - Fax:
Practice Address - Street 1:121 W MAPLE AVE
Practice Address - Street 2:
Practice Address - City:ENID
Practice Address - State:OK
Practice Address - Zip Code:73701-4027
Practice Address - Country:US
Practice Address - Phone:580-984-1115
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-04-22
Last Update Date:2021-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK12659854717OtherBLUE CROSS AND BLUE SHIELD OK