Provider Demographics
NPI:1114407202
Name:OKLAHOMA NUTRITION THERAPY, PLLC
Entity Type:Organization
Organization Name:OKLAHOMA NUTRITION THERAPY, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LISA
Authorized Official - Middle Name:
Authorized Official - Last Name:GIBSON
Authorized Official - Suffix:
Authorized Official - Credentials:RDN
Authorized Official - Phone:405-314-0953
Mailing Address - Street 1:3351 W ROCK CREEK RD STE 120
Mailing Address - Street 2:
Mailing Address - City:NORMAN
Mailing Address - State:OK
Mailing Address - Zip Code:73072-2463
Mailing Address - Country:US
Mailing Address - Phone:405-314-0953
Mailing Address - Fax:405-701-5950
Practice Address - Street 1:3351 W ROCK CREEK RD STE 120
Practice Address - Street 2:
Practice Address - City:NORMAN
Practice Address - State:OK
Practice Address - Zip Code:73072-2463
Practice Address - Country:US
Practice Address - Phone:405-314-0953
Practice Address - Fax:405-701-5950
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-08-17
Last Update Date:2018-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK1436133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Single Specialty