Healthcare Provider Details

I. General information

NPI: 1306271663
Provider Name (Legal Business Name): ANDRA LANE WINGO B.S.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/05/2013
Last Update Date: 09/05/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

413 N BUGG ST
BOKCHITO OK
74726-1211
US

IV. Provider business mailing address

413 N BUGG ST
BOKCHITO OK
74726-1211
US

V. Phone/Fax

Practice location:
  • Phone: 580-380-7999
  • Fax: 580-564-7309
Mailing address:
  • Phone: 580-380-7999
  • Fax: 580-564-7309

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: