MEDICARE: MRS. FAYE WILSON

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	171M00000X	Case Manager/Care Coordinator	M000622408	OK

General Provider Information

NPI Number	:	1689106114
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. FAYE WILSON

Provider Business Mailing Address
First Line	:	6901 SE 162ND ST
Second Line	:
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73165-6849
Country	:	US
Telephone Number	:	405-210-7119
Fax Number	:

Provider Business Practice Location Address
First Line	:	6901 SE 162ND ST
Second Line	:
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73165-6849
Country	:	US
Telephone Number	:	405-210-7119
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/03/2017
Last Update Date	:	04/03/2017

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