1245573583 NPI number — MRS. APRIL LYNN WIGLEY-ELLIOTT LMT

Table of content: MRS. APRIL LYNN WIGLEY-ELLIOTT LMT (NPI 1245573583)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1245573583 NPI number — MRS. APRIL LYNN WIGLEY-ELLIOTT LMT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WIGLEY-ELLIOTT
Provider First Name:
APRIL
Provider Middle Name:
LYNN
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
LMT
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1245573583
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/21/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4316 TRINITY DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SHAWNEE
Provider Business Mailing Address State Name:
OK
Provider Business Mailing Address Postal Code:
74804-8965
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
580-235-8047
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
119 N BROADWAY AVE STE 10
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ADA
Provider Business Practice Location Address State Name:
OK
Provider Business Practice Location Address Postal Code:
74820
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
580-235-8047
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
04/05/2013

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 225700000X , with the licence number:  172582 , registered in the state of OK ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 225700000X , with the licence number: MT103888 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 172582 . This is a "OK STATE BOARD OF COSMETOLOGY" identifier , issued by the state of ( OK ) . This identifiers is of the category "OTHER".
  • Identifier: MT103888 . This is a "STATE OF TEXAS" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".




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