=====================================================
General NPI Number Information
=====================================================
NPI Number | 1578281390
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | LISA CAROLIN WILMETH NP
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/17/2022
-----------------------------------------------------
Last Update Date | 08/17/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1202 SW 67TH ST
-----------------------------------------------------
City | LAWTON
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 73505-7437
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 818-749-1203
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 706 FILLMORE ST
-----------------------------------------------------
City | WICHITA FALLS
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76301-4013
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 940-235-9743
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number | 209852
-----------------------------------------------------
License Number State | OK
-----------------------------------------------------