Provider Demographics
NPI:1043841893
Name:WERNEBURG, CODY
Entity Type:Individual
Prefix:
First Name:CODY
Middle Name:
Last Name:WERNEBURG
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5246 MOCKINGBIRD LN
Mailing Address - Street 2:
Mailing Address - City:BLANCHARD
Mailing Address - State:OK
Mailing Address - Zip Code:73010-7814
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3300 HEALTHPLEX PKWY
Practice Address - Street 2:
Practice Address - City:NORMAN
Practice Address - State:OK
Practice Address - Zip Code:73072-9749
Practice Address - Country:US
Practice Address - Phone:405-515-2131
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-01-30
Last Update Date:2020-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes136A00000XDietary & Nutritional Service ProvidersDietetic Technician, Registered