Healthcare Provider Details

I. General information

NPI: 1679098917
Provider Name (Legal Business Name): AVA LEE POINDEXTER FWSP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MRS. AVA LEE WAGGONER

II. Dates (important events)

Enumeration Date: 08/08/2017
Last Update Date: 03/10/2025
Certification Date: 03/10/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1108 N WHEELER AVE
SALLISAW OK
74955-2227
US

IV. Provider business mailing address

PO BOX 117
GANS OK
74936-0117
US

V. Phone/Fax

Practice location:
  • Phone: 918-775-5513
  • Fax:
Mailing address:
  • Phone: 918-315-2799
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: