Provider Demographics
NPI:1215222666
Name:WILSON, JANENA GRACE (FNP)
Entity Type:Individual
Prefix:
First Name:JANENA
Middle Name:GRACE
Last Name:WILSON
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:806 MANVEL AVE
Mailing Address - Street 2:
Mailing Address - City:CHANDLER
Mailing Address - State:OK
Mailing Address - Zip Code:74834-3858
Mailing Address - Country:US
Mailing Address - Phone:405-258-9955
Mailing Address - Fax:405-258-9930
Practice Address - Street 1:806 MANVEL AVE
Practice Address - Street 2:
Practice Address - City:CHANDLER
Practice Address - State:OK
Practice Address - Zip Code:74834
Practice Address - Country:US
Practice Address - Phone:405-258-9955
Practice Address - Fax:405-258-9930
Is Sole Proprietor?:No
Enumeration Date:2011-06-14
Last Update Date:2018-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK86757363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily