Provider Demographics
NPI:1588239842
Name:WISEMAN, TONYA LYNN
Entity Type:Individual
Prefix:
First Name:TONYA
Middle Name:LYNN
Last Name:WISEMAN
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 1:313 E PEAK BLVD
Mailing Address - Street 2:
Mailing Address - City:MUSKOGEE
Mailing Address - State:OK
Mailing Address - Zip Code:74403-8515
Mailing Address - Country:US
Mailing Address - Phone:918-683-0273
Mailing Address - Fax:
Practice Address - Street 1:313 E PEAK BLVD
Practice Address - Street 2:
Practice Address - City:MUSKOGEE
Practice Address - State:OK
Practice Address - Zip Code:74403-8515
Practice Address - Country:US
Practice Address - Phone:918-683-0273
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-05-20
Last Update Date:2021-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK3499235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist