Provider Demographics
NPI:1275956062
Name:NOURISH NUTRITION & DIABETES LLC
Entity Type:Organization
Organization Name:NOURISH NUTRITION & DIABETES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER AND DIETITIAN
Authorized Official - Prefix:
Authorized Official - First Name:LISA
Authorized Official - Middle Name:
Authorized Official - Last Name:JOHNSTON
Authorized Official - Suffix:
Authorized Official - Credentials:RD
Authorized Official - Phone:405-509-1294
Mailing Address - Street 1:3030 NW EXPRESSWAY
Mailing Address - Street 2:SUITE 200-149
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73112-5474
Mailing Address - Country:US
Mailing Address - Phone:405-509-1294
Mailing Address - Fax:
Practice Address - Street 1:3030 NW EXPRESSWAY
Practice Address - Street 2:SUITE 200-149
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73112-5474
Practice Address - Country:US
Practice Address - Phone:405-241-5836
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-01-29
Last Update Date:2017-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK1559133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NONEOtherNONE
OKOKAAA4070Medicare UPIN