Provider Demographics
NPI:1437210408
Name:WINDHAM, TERA BETH (RD LD)
Entity Type:Individual
Prefix:
First Name:TERA
Middle Name:BETH
Last Name:WINDHAM
Suffix:
Gender:F
Credentials:RD LD
Other - Prefix:
Other - First Name:TERA
Other - Middle Name:BETH
Other - Last Name:BOHANON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RD LD
Mailing Address - Street 1:100 S BLISS AVE
Mailing Address - Street 2:
Mailing Address - City:TAHLEQUAH
Mailing Address - State:OK
Mailing Address - Zip Code:74464-2512
Mailing Address - Country:US
Mailing Address - Phone:918-458-3100
Mailing Address - Fax:
Practice Address - Street 1:100 S BLISS AVE
Practice Address - Street 2:
Practice Address - City:TAHLEQUAH
Practice Address - State:OK
Practice Address - Zip Code:74464-2512
Practice Address - Country:US
Practice Address - Phone:918-458-3100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-13
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK1389133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
OKMEDICARE PROVIDER NUMedicare ID - Type UnspecifiedMEDICARE PROVIDER #- WWH
OKMEDICARE UPINMedicare UPIN