Provider Demographics
NPI:1609494558
Name:WILSON, SHRONDA L
Entity type:Individual
Prefix:
First Name:SHRONDA
Middle Name:L
Last Name:WILSON
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 1:5011 S 76TH EAST AVE APT A
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74145-6208
Mailing Address - Country:US
Mailing Address - Phone:918-408-4387
Mailing Address - Fax:
Practice Address - Street 1:1055 S HOUSTON AVE
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74127-9043
Practice Address - Country:US
Practice Address - Phone:918-921-3226
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-07-08
Last Update Date:2020-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist