Provider Demographics
NPI:1528011947
Name:VANN, WENDY YVONNE (MS)
Entity Type:Individual
Prefix:
First Name:WENDY
Middle Name:YVONNE
Last Name:VANN
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:213 W JACKSON AVE
Mailing Address - Street 2:
Mailing Address - City:MCALESTER
Mailing Address - State:OK
Mailing Address - Zip Code:74501-4029
Mailing Address - Country:US
Mailing Address - Phone:918-916-7593
Mailing Address - Fax:918-429-0588
Practice Address - Street 1:213 W JACKSON AVE
Practice Address - Street 2:
Practice Address - City:MCALESTER
Practice Address - State:OK
Practice Address - Zip Code:74501-4029
Practice Address - Country:US
Practice Address - Phone:918-916-7593
Practice Address - Fax:918-429-0588
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-18
Last Update Date:2010-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK1187101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100636540BMedicaid