Provider Demographics
NPI:1023348059
Name:WELLSTON FAMILY MEDICAL CLINIC, PLLC
Entity type:Organization
Organization Name:WELLSTON FAMILY MEDICAL CLINIC, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ARNP
Authorized Official - Prefix:MRS
Authorized Official - First Name:SHERRY
Authorized Official - Middle Name:DIANN
Authorized Official - Last Name:MITCHELL
Authorized Official - Suffix:
Authorized Official - Credentials:FNP-BC
Authorized Official - Phone:405-258-3971
Mailing Address - Street 1:PO BOX 98
Mailing Address - Street 2:
Mailing Address - City:WELLSTON
Mailing Address - State:OK
Mailing Address - Zip Code:74881-0098
Mailing Address - Country:US
Mailing Address - Phone:405-356-2998
Mailing Address - Fax:405-258-0498
Practice Address - Street 1:309 W. 2ND ST.
Practice Address - Street 2:
Practice Address - City:WELLSTON
Practice Address - State:OK
Practice Address - Zip Code:74881
Practice Address - Country:US
Practice Address - Phone:405-356-2998
Practice Address - Fax:405-258-0498
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-01-14
Last Update Date:2010-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKR0080778261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care