Individual
MARQUITA RENEE WILSON
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Contact information
Practice address
1 W 36TH ST N, TULSA, OK 74106-1700
(918) 636-4165
Mailing address
2417 E 48TH ST N, TULSA, OK 74130-2017
(918) 636-4165
Taxonomy
Speciality
Code
Description
License number
State
101Y00000X
Counselor
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
200287120A
—
OK
Enumeration date
09/22/2012
Last updated
09/23/2014
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