Healthcare Provider Details

I. General information

NPI: 1407719610
Provider Name (Legal Business Name): CIERSTEN JEAN WILSON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/04/2025
Last Update Date: 12/04/2025
Certification Date: 12/04/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19320 E ADMIRAL PL STE B
CATOOSA OK
74015-3240
US

IV. Provider business mailing address

19320 E ADMIRAL PL STE B
CATOOSA OK
74015-3240
US

V. Phone/Fax

Practice location:
  • Phone: 918-340-5503
  • Fax: 918-340-5503
Mailing address:
  • Phone: 918-340-5503
  • Fax: 918-340-5503

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: