Healthcare Provider Details

I. General information

NPI: 1861064065
Provider Name (Legal Business Name): ADDISON WREN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/15/2021
Last Update Date: 05/12/2022
Certification Date: 05/12/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

811 E VIRGINIA AVE
STILLWATER OK
74075-7919
US

IV. Provider business mailing address

920 S MURPHY ST APT 8108
STILLWATER OK
74074-1755
US

V. Phone/Fax

Practice location:
  • Phone: 405-377-8255
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License NumberCF369
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: