Provider Demographics
NPI:1750636528
Name:WILSON, DANIELLE NICOLE
Entity Type:Individual
Prefix:MISS
First Name:DANIELLE
Middle Name:NICOLE
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 1:2100 SW 69TH ST
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73159-2949
Mailing Address - Country:US
Mailing Address - Phone:405-589-4147
Mailing Address - Fax:
Practice Address - Street 1:2100 SW 69TH ST
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73159-2949
Practice Address - Country:US
Practice Address - Phone:405-589-4147
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-18
Last Update Date:2012-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health