Provider Demographics
NPI:1689894297
Name:BOSTIC-BROWN, MISTY MECHELLE (BS)
Entity Type:Individual
Prefix:MRS
First Name:MISTY
Middle Name:MECHELLE
Last Name:BOSTIC-BROWN
Suffix:
Gender:F
Credentials:BS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5000 SE 53RD ST
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73135-4302
Mailing Address - Country:US
Mailing Address - Phone:405-706-7173
Mailing Address - Fax:405-525-7867
Practice Address - Street 1:5000 SE 53RD ST
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73135-4302
Practice Address - Country:US
Practice Address - Phone:405-706-7173
Practice Address - Fax:405-525-7867
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK251B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251B00000XAgenciesCase Management