Provider Demographics
NPI:1225622947
Name:WILSON, ELSA CHANTILE
Entity Type:Individual
Prefix:
First Name:ELSA
Middle Name:CHANTILE
Last Name:WILSON
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 1:454 S INDIANAPOLIS AVE
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74112-2626
Mailing Address - Country:US
Mailing Address - Phone:509-638-9294
Mailing Address - Fax:
Practice Address - Street 1:6016 S 66TH EAST AVE
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74145-9210
Practice Address - Country:US
Practice Address - Phone:918-764-9098
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-02-23
Last Update Date:2021-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator