Provider Demographics
NPI:1215238514
Name:WILSON, TONYA DAILWAYNE
Entity type:Individual
Prefix:MRS
First Name:TONYA
Middle Name:DAILWAYNE
Last Name:WILSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4016 SE 24TH ST
Mailing Address - Street 2:
Mailing Address - City:DEL CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73115-2526
Mailing Address - Country:US
Mailing Address - Phone:479-619-6296
Mailing Address - Fax:
Practice Address - Street 1:4016 S.E. 24TH STREET
Practice Address - Street 2:
Practice Address - City:DEL CITY
Practice Address - State:OK
Practice Address - Zip Code:73115
Practice Address - Country:US
Practice Address - Phone:479-619-6296
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-11-03
Last Update Date:2010-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health