Provider Demographics
NPI:1700642188
Name:MCMILLAN, BREENE AUDREY LYNN (LMT)
Entity Type:Individual
Prefix:
First Name:BREENE
Middle Name:AUDREY LYNN
Last Name:MCMILLAN
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1200 KELLY PARK RD
Mailing Address - Street 2:
Mailing Address - City:EDMOND
Mailing Address - State:OK
Mailing Address - Zip Code:73003-5850
Mailing Address - Country:US
Mailing Address - Phone:405-441-5641
Mailing Address - Fax:
Practice Address - Street 1:5300 N MERIDIAN AVE STE 6
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73112-2137
Practice Address - Country:US
Practice Address - Phone:405-441-5641
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-02-23
Last Update Date:2024-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK197844225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist