Provider Demographics
NPI:1083154405
Name:MADORE, RENEE (RDN, LD)
Entity Type:Individual
Prefix:MS
First Name:RENEE
Middle Name:
Last Name:MADORE
Suffix:
Gender:F
Credentials:RDN, LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3706 EDMOND RD NE
Mailing Address - Street 2:
Mailing Address - City:PIEDMONT
Mailing Address - State:OK
Mailing Address - Zip Code:73078-9239
Mailing Address - Country:US
Mailing Address - Phone:405-206-6031
Mailing Address - Fax:
Practice Address - Street 1:3706 EDMOND RD NE
Practice Address - Street 2:
Practice Address - City:PIEDMONT
Practice Address - State:OK
Practice Address - Zip Code:73078-9239
Practice Address - Country:US
Practice Address - Phone:405-206-6031
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-03-04
Last Update Date:2017-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK2190133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered