Provider Demographics
NPI:1235809906
Name:WISDOM, LESLEY DAWN (CPRSS)
Entity Type:Individual
Prefix:
First Name:LESLEY
Middle Name:DAWN
Last Name:WISDOM
Suffix:
Gender:F
Credentials:CPRSS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6503 W 415 RD
Mailing Address - Street 2:
Mailing Address - City:ADAIR
Mailing Address - State:OK
Mailing Address - Zip Code:74330-2854
Mailing Address - Country:US
Mailing Address - Phone:918-638-4824
Mailing Address - Fax:
Practice Address - Street 1:4238 NE 1ST ST
Practice Address - Street 2:
Practice Address - City:PRYOR
Practice Address - State:OK
Practice Address - Zip Code:74361-9614
Practice Address - Country:US
Practice Address - Phone:918-825-1930
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-09-15
Last Update Date:2021-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist