Provider Demographics
NPI:1790020873
Name:WILSON, MIKEYA
Entity Type:Individual
Prefix:
First Name:MIKEYA
Middle Name:
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 1:5550 S GARNETT RD
Mailing Address - Street 2:100
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74146-6831
Mailing Address - Country:US
Mailing Address - Phone:918-665-2501
Mailing Address - Fax:
Practice Address - Street 1:5550 S GARNETT RD
Practice Address - Street 2:100
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74146-6831
Practice Address - Country:US
Practice Address - Phone:918-665-2501
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-11-30
Last Update Date:2012-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374700000XNursing Service Related ProvidersTechnician