Provider Demographics
NPI:1609123942
Name:WILSON, MICHELLE N
Entity Type:Individual
Prefix:MISS
First Name:MICHELLE
Middle Name:N
Last Name:WILSON
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 1:2416 BARCLAY RD
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73120-3520
Mailing Address - Country:US
Mailing Address - Phone:405-488-5665
Mailing Address - Fax:
Practice Address - Street 1:7905 E US HIGHWAY 66
Practice Address - Street 2:
Practice Address - City:EL RENO
Practice Address - State:OK
Practice Address - Zip Code:73036-9225
Practice Address - Country:US
Practice Address - Phone:405-264-5559
Practice Address - Fax:405-264-5502
Is Sole Proprietor?:Yes
Enumeration Date:2012-08-06
Last Update Date:2012-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator