Provider Demographics
NPI:1225026008
Name:GOSS, DENISE MICHELLE (RD/LD,CDE)
Entity Type:Individual
Prefix:MRS
First Name:DENISE
Middle Name:MICHELLE
Last Name:GOSS
Suffix:
Gender:F
Credentials:RD/LD,CDE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24885 S 470 RD
Mailing Address - Street 2:
Mailing Address - City:TAHLEQUAH
Mailing Address - State:OK
Mailing Address - Zip Code:74464-1518
Mailing Address - Country:US
Mailing Address - Phone:918-453-0238
Mailing Address - Fax:
Practice Address - Street 1:1805 N YORK ST
Practice Address - Street 2:STE E
Practice Address - City:MUSKOGEE
Practice Address - State:OK
Practice Address - Zip Code:74403-1404
Practice Address - Country:US
Practice Address - Phone:918-687-0201
Practice Address - Fax:918-687-0665
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-10-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKLD876133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered