Healthcare Provider Details

I. General information

NPI: 1861695611
Provider Name (Legal Business Name): TRACI L WILKERSON AUD INC PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/08/2007
Last Update Date: 07/18/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3312 W OKMULGEE ST
MUSKOGEE OK
74401-5069
US

IV. Provider business mailing address

3312 W OKMULGEE ST
MUSKOGEE OK
74401-5069
US

V. Phone/Fax

Practice location:
  • Phone: 918-682-1515
  • Fax: 918-682-1598
Mailing address:
  • Phone: 918-682-1515
  • Fax: 918-682-1598

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code231H00000X
TaxonomyAudiologist
License Number144
License Number StateOK
# 2
Primary TaxonomyN
Taxonomy Code231HA2500X
TaxonomyAssistive Technology Supplier Audiologist
License Number144
License Number StateOK
# 3
Primary TaxonomyN
Taxonomy Code237600000X
TaxonomyAudiologist-Hearing Aid Fitter
License Number144
License Number StateOK

VIII. Authorized Official

Name: MRS. TRACI L WILKERSON
Title or Position: OWNER/PRACTITIONER
Credential: AUD
Phone: 918-682-1515