Provider Demographics
NPI:1548479918
Name:WADE, GEORGIA ANN (RN IBCLC)
Entity type:Individual
Prefix:
First Name:GEORGIA
Middle Name:ANN
Last Name:WADE
Suffix:
Gender:F
Credentials:RN IBCLC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 N 67TH ST
Mailing Address - Street 2:
Mailing Address - City:BROKEN ARROW
Mailing Address - State:OK
Mailing Address - Zip Code:74014-6945
Mailing Address - Country:US
Mailing Address - Phone:918-357-1404
Mailing Address - Fax:
Practice Address - Street 1:100 N 67TH ST
Practice Address - Street 2:
Practice Address - City:BROKEN ARROW
Practice Address - State:OK
Practice Address - Zip Code:74014-6945
Practice Address - Country:US
Practice Address - Phone:918-357-1404
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKR0033022163WL0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WL0100XNursing Service ProvidersRegistered NurseLactation Consultant
Provider Identifiers
StateIdentifier IDID TypeIssuer
OKR0033022OtherREGISTERED NURSE
OK163WL0100XOtherRN. LACTATION CONSULTANT