Provider Demographics
NPI:1528186723
Name:GIBSON, LISA C (MS, RD, LD)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:C
Last Name:GIBSON
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 1:2102 WHEATON DR
Mailing Address - Street 2:
Mailing Address - City:NORMAN
Mailing Address - State:OK
Mailing Address - Zip Code:73071-7356
Mailing Address - Country:US
Mailing Address - Phone:405-701-2487
Mailing Address - Fax:
Practice Address - Street 1:6003 N ROBINSON AVE
Practice Address - Street 2:SUITE 103
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73118-7425
Practice Address - Country:US
Practice Address - Phone:405-314-0953
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-26
Last Update Date:2008-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK1436133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered