Provider Demographics
NPI:1891166864
Name:MADISON, WENDY DENISE (CNP)
Entity Type:Individual
Prefix:
First Name:WENDY
Middle Name:DENISE
Last Name:MADISON
Suffix:
Gender:F
Credentials:CNP
Other - Prefix:
Other - First Name:WENDY
Other - Middle Name:
Other - Last Name:SMITH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN
Mailing Address - Street 1:119 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:HOMINY
Mailing Address - State:OK
Mailing Address - Zip Code:74035-1031
Mailing Address - Country:US
Mailing Address - Phone:918-885-4640
Mailing Address - Fax:918-885-4644
Practice Address - Street 1:119 W MAIN ST
Practice Address - Street 2:
Practice Address - City:HOMINY
Practice Address - State:OK
Practice Address - Zip Code:74035-1031
Practice Address - Country:US
Practice Address - Phone:918-885-4640
Practice Address - Fax:918-885-4644
Is Sole Proprietor?:No
Enumeration Date:2015-10-15
Last Update Date:2017-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK84648363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK449026YRHZOtherMEDICARE PTAN
OK200614820 AMedicaid