Provider Demographics
NPI:1861004541
Name:WILSON, WETAHANNA
Entity Type:Individual
Prefix:MS
First Name:WETAHANNA
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 1:3057 OVERLAND DR
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73115-1815
Mailing Address - Country:US
Mailing Address - Phone:405-754-9333
Mailing Address - Fax:
Practice Address - Street 1:7901 NE 10TH ST STE B101
Practice Address - Street 2:
Practice Address - City:MIDWEST CITY
Practice Address - State:OK
Practice Address - Zip Code:73110-3653
Practice Address - Country:US
Practice Address - Phone:405-250-8910
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-23
Last Update Date:2020-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker