Provider Demographics
NPI:1700246634
Name:WRIGHT, SHANTWYNICE
Entity Type:Individual
Prefix:
First Name:SHANTWYNICE
Middle Name:
Last Name:WRIGHT
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 1:6504 NW OAK AVE APT C7
Mailing Address - Street 2:
Mailing Address - City:LAWTON
Mailing Address - State:OK
Mailing Address - Zip Code:73505-4340
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2215 NW CACHE RD
Practice Address - Street 2:STE 107
Practice Address - City:LAWTON
Practice Address - State:OK
Practice Address - Zip Code:73505-5239
Practice Address - Country:US
Practice Address - Phone:580-351-9998
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-03-04
Last Update Date:2016-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator