Provider Demographics
NPI:1881198125
Name:WINGO, SHELLY MARIE
Entity Type:Individual
Prefix:MS
First Name:SHELLY
Middle Name:MARIE
Last Name:WINGO
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:PO BOX 14
Mailing Address - Street 2:
Mailing Address - City:WAYNOKA
Mailing Address - State:OK
Mailing Address - Zip Code:73860-0014
Mailing Address - Country:US
Mailing Address - Phone:405-625-7972
Mailing Address - Fax:
Practice Address - Street 1:1539 WAYNOKA ST
Practice Address - Street 2:
Practice Address - City:WAYNOKA
Practice Address - State:OK
Practice Address - Zip Code:73860-1353
Practice Address - Country:US
Practice Address - Phone:405-625-7972
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-03-21
Last Update Date:2018-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator