Provider Demographics
NPI:1871891861
Name:BRAZEAL, WANDA KAYE (FPMHNP)
Entity type:Individual
Prefix:
First Name:WANDA
Middle Name:KAYE
Last Name:BRAZEAL
Suffix:
Gender:F
Credentials:FPMHNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 21228
Mailing Address - Street 2:DEPARTMENT 31
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74121-1228
Mailing Address - Country:US
Mailing Address - Phone:918-491-3700
Mailing Address - Fax:
Practice Address - Street 1:6655 S YALE AVE
Practice Address - Street 2:LAUREATE PSYCHIATRIC CLINIC AND HOSPITAL
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74136-3326
Practice Address - Country:US
Practice Address - Phone:918-491-3700
Practice Address - Fax:918-491-5740
Is Sole Proprietor?:No
Enumeration Date:2011-03-01
Last Update Date:2011-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK72748363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200329080AMedicaid
OKOKAAA0507Medicare PIN