Provider Demographics
NPI:1558140103
Name:YOUNG, WAYLEN
Entity Type:Individual
Prefix:
First Name:WAYLEN
Middle Name:
Last Name:YOUNG
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2504 SW JEFFERSON AVE LOT 17
Mailing Address - Street 2:
Mailing Address - City:LAWTON
Mailing Address - State:OK
Mailing Address - Zip Code:73505-8636
Mailing Address - Country:US
Mailing Address - Phone:580-699-6996
Mailing Address - Fax:
Practice Address - Street 1:1503 W GORE BLVD
Practice Address - Street 2:
Practice Address - City:LAWTON
Practice Address - State:OK
Practice Address - Zip Code:73501-3608
Practice Address - Country:US
Practice Address - Phone:580-448-0461
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-09-25
Last Update Date:2023-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator