Provider Demographics
NPI:1043332281
Name:WETHERILL, MARIANNA SUSAN (PHD, MPH, RDN-AP/LD)
Entity Type:Individual
Prefix:DR
First Name:MARIANNA
Middle Name:SUSAN
Last Name:WETHERILL
Suffix:
Gender:F
Credentials:PHD, MPH, RDN-AP/LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1548 E 34TH ST
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74105-2620
Mailing Address - Country:US
Mailing Address - Phone:918-853-1877
Mailing Address - Fax:
Practice Address - Street 1:591 E. 36 ST. STREET NORTH
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74106-1872
Practice Address - Country:US
Practice Address - Phone:918-619-8700
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-06
Last Update Date:2016-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK1365133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered