Provider Demographics
NPI:1437830882
Name:WILEY, FAYETTE LOUISE
Entity Type:Individual
Prefix:
First Name:FAYETTE
Middle Name:LOUISE
Last Name:WILEY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:FAY
Other - Middle Name:LOUISE
Other - Last Name:WILEY
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:109 S HARRILL AVE
Mailing Address - Street 2:
Mailing Address - City:WAGONER
Mailing Address - State:OK
Mailing Address - Zip Code:74467-5317
Mailing Address - Country:US
Mailing Address - Phone:918-485-0242
Mailing Address - Fax:918-485-0204
Practice Address - Street 1:109 S HARRILL AVE
Practice Address - Street 2:
Practice Address - City:WAGONER
Practice Address - State:OK
Practice Address - Zip Code:74467-5317
Practice Address - Country:US
Practice Address - Phone:918-485-0242
Practice Address - Fax:918-485-0204
Is Sole Proprietor?:No
Enumeration Date:2023-07-28
Last Update Date:2023-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK1437830882175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist