Healthcare Provider Details

I. General information

NPI: 1447093497
Provider Name (Legal Business Name): MANDY JEAN WIGGIN PRSS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/17/2024
Last Update Date: 03/03/2025
Certification Date: 03/03/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1015 W WASHBOURNE ST
JAY OK
74346-4205
US

IV. Provider business mailing address

1015 W WASHBOURNE ST
JAY OK
74346-4205
US

V. Phone/Fax

Practice location:
  • Phone: 918-308-5513
  • Fax:
Mailing address:
  • Phone: 918-308-5513
  • Fax: 918-253-6645

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License Number1447093497
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: