Provider Demographics
NPI:1083137442
Name:WISEMAN, LOUANN
Entity Type:Individual
Prefix:
First Name:LOUANN
Middle Name:
Last Name:WISEMAN
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 1:1302 W ELM AVE
Mailing Address - Street 2:
Mailing Address - City:DUNCAN
Mailing Address - State:OK
Mailing Address - Zip Code:73533-4753
Mailing Address - Country:US
Mailing Address - Phone:580-606-2419
Mailing Address - Fax:
Practice Address - Street 1:1404 W MAIN ST
Practice Address - Street 2:
Practice Address - City:DUNCAN
Practice Address - State:OK
Practice Address - Zip Code:73533-4331
Practice Address - Country:US
Practice Address - Phone:580-606-2419
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-07-18
Last Update Date:2018-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171W00000XOther Service ProvidersContractorGroup - Single Specialty