Provider Demographics
NPI:1245986629
Name:PEMBROOK, MAGGIE LYNN
Entity type:Individual
Prefix:MS
First Name:MAGGIE
Middle Name:LYNN
Last Name:PEMBROOK
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 1:2705 S BEECH AVE
Mailing Address - Street 2:
Mailing Address - City:BROKEN ARROW
Mailing Address - State:OK
Mailing Address - Zip Code:74012-7306
Mailing Address - Country:US
Mailing Address - Phone:918-645-8262
Mailing Address - Fax:
Practice Address - Street 1:102 N DENVER AVE
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74103-1806
Practice Address - Country:US
Practice Address - Phone:918-582-1200
Practice Address - Fax:918-560-1399
Is Sole Proprietor?:No
Enumeration Date:2022-02-24
Last Update Date:2022-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK171M00000XMedicaid