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General NPI Number Information
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NPI Number | 1265149140
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Entity Type | Organization
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Legal Business Name | WYNNEWOOD WELLNESS CLINIC
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Dates
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Enumeration Date | 11/01/2022
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Last Update Date | 11/01/2022
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Provider Practice Location Address
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Address Line | 1202 E KERR BLVD
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City | WYNNEWOOD
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State | OK
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Zip | 73098-2054
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Country | US
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Telephone | 405-473-3307
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Fax |
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Provider Business Mailing Address
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Address Line | 1516 SW 82ND CIR
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City | OKLAHOMA CITY
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State | OK
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Zip | 73159-5943
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Country | US
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Telephone | 405-473-3307
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Fax |
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Authorized Official
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Title or Position | APRN
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Name | MRS. KARISA JO KENNEDY
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Credential | APRN
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Telephone | 405-473-3307
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QR1300X
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Taxonomy Name | Rural Health Clinic/Center
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License Number |
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License Number State |
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