Provider Demographics
NPI:1346558616
Name:DEDERICK, SHELBY LYNN (RD/LD)
Entity Type:Individual
Prefix:MS
First Name:SHELBY
Middle Name:LYNN
Last Name:DEDERICK
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 1:4304 E 52ND PL
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74135-3915
Mailing Address - Country:US
Mailing Address - Phone:785-554-2497
Mailing Address - Fax:
Practice Address - Street 1:4304 E 52ND PL
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74135-3915
Practice Address - Country:US
Practice Address - Phone:785-554-2497
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-09-20
Last Update Date:2010-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK1533133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered