Provider Demographics
NPI:1760179790
Name:SHELLHORSE, BREANNA LEIGH
Entity Type:Individual
Prefix:
First Name:BREANNA
Middle Name:LEIGH
Last Name:SHELLHORSE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1923 N CLASSEN BLVD
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73106-6005
Mailing Address - Country:US
Mailing Address - Phone:405-856-5801
Mailing Address - Fax:
Practice Address - Street 1:1923 N CLASSEN BLVD
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73106-6005
Practice Address - Country:US
Practice Address - Phone:405-856-5801
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-04-19
Last Update Date:2023-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist