Provider Demographics
NPI:1144343849
Name:SOUTHARD, MARY NELL (RD,LD)
Entity type:Individual
Prefix:MS
First Name:MARY
Middle Name:NELL
Last Name:SOUTHARD
Suffix:
Gender:F
Credentials: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:HC 69 BOX 245
Mailing Address - Street 2:
Mailing Address - City:SNOW
Mailing Address - State:OK
Mailing Address - Zip Code:74567-9717
Mailing Address - Country:US
Mailing Address - Phone:918-755-4364
Mailing Address - Fax:
Practice Address - Street 1:1 CHOCTAW WAY
Practice Address - Street 2:NUTRITION SERVICES
Practice Address - City:TALIHINA
Practice Address - State:OK
Practice Address - Zip Code:74571-2022
Practice Address - Country:US
Practice Address - Phone:918-567-7000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK119133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
OKP88458Medicare UPIN