Provider Demographics
NPI:1477808335
Name:LASSITER, WANDA L
Entity Type:Individual
Prefix:
First Name:WANDA
Middle Name:L
Last Name:LASSITER
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 1:13036 SW 5TH TER
Mailing Address - Street 2:
Mailing Address - City:YUKON
Mailing Address - State:OK
Mailing Address - Zip Code:73099-0506
Mailing Address - Country:US
Mailing Address - Phone:580-298-3001
Mailing Address - Fax:580-298-5357
Practice Address - Street 1:903 W MAIN ST
Practice Address - Street 2:
Practice Address - City:ANTLERS
Practice Address - State:OK
Practice Address - Zip Code:74523-2045
Practice Address - Country:US
Practice Address - Phone:580-298-3001
Practice Address - Fax:580-298-5357
Is Sole Proprietor?:No
Enumeration Date:2012-07-17
Last Update Date:2012-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TR0400XBehavioral Health & Social Service ProvidersPsychologistRehabilitation