Provider Demographics
NPI:1801511142
Name:WIESE, HAILEE LYNN (DPT)
Entity type:Individual
Prefix:
First Name:HAILEE
Middle Name:LYNN
Last Name:WIESE
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1016 E THOMPSON AVE
Mailing Address - Street 2:
Mailing Address - City:SAPULPA
Mailing Address - State:OK
Mailing Address - Zip Code:74066-4509
Mailing Address - Country:US
Mailing Address - Phone:918-688-8409
Mailing Address - Fax:
Practice Address - Street 1:6585 S YALE AVE STE 445
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74136-9703
Practice Address - Country:US
Practice Address - Phone:918-481-2977
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-10-10
Last Update Date:2022-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK5493225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist