Provider Demographics
NPI:1518243252
Name:EDWARDS, CASSANDRA STAR (MS, RD/LD)
Entity Type:Individual
Prefix:
First Name:CASSANDRA
Middle Name:STAR
Last Name:EDWARDS
Suffix:
Gender:F
Credentials:MS, RD/LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3901 N BROADWAY AVE
Mailing Address - Street 2:
Mailing Address - City:ADA
Mailing Address - State:OK
Mailing Address - Zip Code:74820-1109
Mailing Address - Country:US
Mailing Address - Phone:580-371-5183
Mailing Address - Fax:
Practice Address - Street 1:3901 N BROADWAY AVE
Practice Address - Street 2:
Practice Address - City:ADA
Practice Address - State:OK
Practice Address - Zip Code:74820-1109
Practice Address - Country:US
Practice Address - Phone:580-371-5183
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-10-26
Last Update Date:2011-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK1604133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered