Provider Demographics
NPI:1144673112
Name:THE WELLNESS CLINIC
Entity type:Organization
Organization Name:THE WELLNESS CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:NURSE PRACTITIONER
Authorized Official - Prefix:
Authorized Official - First Name:ANNA
Authorized Official - Middle Name:LILIA
Authorized Official - Last Name:PINA
Authorized Official - Suffix:
Authorized Official - Credentials:APRN, NP-C
Authorized Official - Phone:918-734-2362
Mailing Address - Street 1:3562 E 51ST ST
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74135-3518
Mailing Address - Country:US
Mailing Address - Phone:918-313-7351
Mailing Address - Fax:
Practice Address - Street 1:3562 E 51ST ST
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74135-3518
Practice Address - Country:US
Practice Address - Phone:918-313-7351
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-07-14
Last Update Date:2016-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK88067261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
1699039883OtherINDIVIDUAL NPI
OK200455350AMedicaid