Provider Demographics
NPI:1467813428
Name:BURDEN, AMY JOYCE (RD)
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:JOYCE
Last Name:BURDEN
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:AMY
Other - Middle Name:JOYCE
Other - Last Name:ORNELAS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3530 E 21ST PL
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74114-1969
Mailing Address - Country:US
Mailing Address - Phone:918-744-5292
Mailing Address - Fax:
Practice Address - Street 1:3530 E 21ST PL
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74114-1969
Practice Address - Country:US
Practice Address - Phone:918-744-5292
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-03-17
Last Update Date:2016-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK2129133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered