Provider Demographics
NPI:1043751241
Name:CRUTCHFIELD, MALLORY (MS, RD/LD)
Entity Type:Individual
Prefix:
First Name:MALLORY
Middle Name:
Last Name:CRUTCHFIELD
Suffix:
Gender:F
Credentials:MS, RD/LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8735 E 46TH PL
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74145-7101
Mailing Address - Country:US
Mailing Address - Phone:918-728-1535
Mailing Address - Fax:
Practice Address - Street 1:8801 S 101ST EAST AVE
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74133-5716
Practice Address - Country:US
Practice Address - Phone:918-294-4070
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-03-20
Last Update Date:2017-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK1821319278133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered