Provider Demographics
NPI:1538963061
Name:BRANNON, KENNEDIE ADISON
Entity type:Individual
Prefix:MS
First Name:KENNEDIE
Middle Name:ADISON
Last Name:BRANNON
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1150 E SH 152
Mailing Address - Street 2:
Mailing Address - City:MUSTANG
Mailing Address - State:OK
Mailing Address - Zip Code:73064-5116
Mailing Address - Country:US
Mailing Address - Phone:405-256-6011
Mailing Address - Fax:405-256-6608
Practice Address - Street 1:1150 E SH 152
Practice Address - Street 2:
Practice Address - City:MUSTANG
Practice Address - State:OK
Practice Address - Zip Code:73064-5116
Practice Address - Country:US
Practice Address - Phone:405-256-6011
Practice Address - Fax:405-256-6603
Is Sole Proprietor?:Yes
Enumeration Date:2025-04-03
Last Update Date:2025-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKE084210095171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator