Healthcare Provider Details

I. General information

NPI: 1295514982
Provider Name (Legal Business Name): 1984ANW PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/22/2023
Last Update Date: 05/08/2026
Certification Date: 05/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15121 TRADITIONS LAKE PKWY STE A
EDMOND OK
73013-1197
US

IV. Provider business mailing address

15121 TRADITIONS LAKE PKWY STE A
EDMOND OK
73013-1197
US

V. Phone/Fax

Practice location:
  • Phone: 405-775-9872
  • Fax: 405-544-2310
Mailing address:
  • Phone: 405-775-9872
  • Fax: 405-544-2310

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: ASHLEY NICOLE WIGINGTON
Title or Position: NURSE PRACTITIONER/OWNER
Credential: APRN, PMHNP-BC
Phone: 405-775-9872