Provider Demographics
NPI:1386368256
Name:KHEZRI, BROOKE
Entity type:Individual
Prefix:
First Name:BROOKE
Middle Name:
Last Name:KHEZRI
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 1:11613 N ROSS AVE
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73120-6514
Mailing Address - Country:US
Mailing Address - Phone:918-606-1305
Mailing Address - Fax:
Practice Address - Street 1:920 STANTON L YOUNG BLVD # WP1140
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73104-5036
Practice Address - Country:US
Practice Address - Phone:405-271-4700
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-10-03
Last Update Date:2023-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK211279207L00000X
OK118871163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
No163W00000XNursing Service ProvidersRegistered Nurse