Provider Demographics
NPI:1760827281
Name:GANN, BRENDA S
Entity Type:Individual
Prefix:
First Name:BRENDA
Middle Name:S
Last Name:GANN
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 1:22808 HILLTOP ROAD
Mailing Address - Street 2:
Mailing Address - City:POTEAU
Mailing Address - State:OKLAHOMA
Mailing Address - Zip Code:74953
Mailing Address - Country:UM
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:111 S MAIN ST
Practice Address - Street 2:
Practice Address - City:MCALESTER
Practice Address - State:OK
Practice Address - Zip Code:74501-5363
Practice Address - Country:US
Practice Address - Phone:918-721-3290
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-05-10
Last Update Date:2013-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251B00000XAgenciesCase Management