Provider Demographics
NPI:1427665660
Name:WILSON, LORI LYN
Entity type:Individual
Prefix:
First Name:LORI
Middle Name:LYN
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 1:12700 SW 53RD ST
Mailing Address - Street 2:
Mailing Address - City:MUSTANG
Mailing Address - State:OK
Mailing Address - Zip Code:73064-7257
Mailing Address - Country:US
Mailing Address - Phone:405-503-1073
Mailing Address - Fax:
Practice Address - Street 1:12700 SW 53RD ST
Practice Address - Street 2:
Practice Address - City:MUSTANG
Practice Address - State:OK
Practice Address - Zip Code:73064-7257
Practice Address - Country:US
Practice Address - Phone:405-503-1073
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-30
Last Update Date:2020-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist