Provider Demographics
NPI:1306271663
Name:WINGO, ANDRA LANE (BS)
Entity type:Individual
Prefix:
First Name:ANDRA
Middle Name:LANE
Last Name:WINGO
Suffix:
Gender:F
Credentials:BS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:413 N BUGG ST
Mailing Address - Street 2:
Mailing Address - City:BOKCHITO
Mailing Address - State:OK
Mailing Address - Zip Code:74726-1211
Mailing Address - Country:US
Mailing Address - Phone:580-380-7999
Mailing Address - Fax:580-564-7309
Practice Address - Street 1:413 N BUGG ST
Practice Address - Street 2:
Practice Address - City:BOKCHITO
Practice Address - State:OK
Practice Address - Zip Code:74726-1211
Practice Address - Country:US
Practice Address - Phone:580-380-7999
Practice Address - Fax:580-564-7309
Is Sole Proprietor?:Yes
Enumeration Date:2013-09-05
Last Update Date:2013-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health