Provider Demographics
NPI:1700480019
Name:WALL, MISTI DAWN
Entity Type:Individual
Prefix:
First Name:MISTI
Middle Name:DAWN
Last Name:WALL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MISTI
Other - Middle Name:DAWN
Other - Last Name:COON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:OVERFELT
Mailing Address - Street 1:1624 CIMARRON PLZ
Mailing Address - Street 2:
Mailing Address - City:STILLWATER
Mailing Address - State:OK
Mailing Address - Zip Code:74075-3467
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1624 CIMARRON PLZ
Practice Address - Street 2:
Practice Address - City:STILLWATER
Practice Address - State:OK
Practice Address - Zip Code:74075-3467
Practice Address - Country:US
Practice Address - Phone:405-372-2202
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-27
Last Update Date:2021-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist