Individual
SHADAVA DEANN WALLACE
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Contact information
Practice address
136 MEADOWVIEW ST, HUGO, OK 74743-5402
(580) 424-4239
Mailing address
136 MEADOWVIEW ST, HUGO, OK 74743-5402
(580) 424-4239
Taxonomy
Speciality
Code
Description
License number
State
101Y00000X
Counselor
Primary
—
OK
Other
Enumeration date
08/22/2022
Last updated
08/22/2022
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