Provider Demographics
NPI:1245945922
Name:WILSON, ELIZABETH ANN
Entity type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:ANN
Last Name:WILSON
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:ELIZABETH
Other - Middle Name:ANN
Other - Last Name:SWARTZENDRUBER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:6221 W GORE BLVD
Mailing Address - Street 2:
Mailing Address - City:LAWTON
Mailing Address - State:OK
Mailing Address - Zip Code:73505-5836
Mailing Address - Country:US
Mailing Address - Phone:580-713-1126
Mailing Address - Fax:
Practice Address - Street 1:6221 W GORE BLVD
Practice Address - Street 2:
Practice Address - City:LAWTON
Practice Address - State:OK
Practice Address - Zip Code:73505-5836
Practice Address - Country:US
Practice Address - Phone:580-351-9998
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-01-18
Last Update Date:2025-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK317531251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes251S00000XAgenciesCommunity/Behavioral HealthGroup - Single Specialty