Provider Demographics
NPI:1447021290
Name:BRUNER, KEIYONNA FAYELIN
Entity type:Individual
Prefix:MRS
First Name:KEIYONNA
Middle Name:FAYELIN
Last Name:BRUNER
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 1:9905 S 236TH EAST AVE
Mailing Address - Street 2:
Mailing Address - City:BROKEN ARROW
Mailing Address - State:OK
Mailing Address - Zip Code:74014-6862
Mailing Address - Country:US
Mailing Address - Phone:918-944-9784
Mailing Address - Fax:
Practice Address - Street 1:6703 E 81ST ST STE E
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74133-4157
Practice Address - Country:US
Practice Address - Phone:918-494-0929
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-01-10
Last Update Date:2024-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK215765363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily