Provider Demographics
NPI:1558320804
Name:SHULTZ, MICHELLE DIANNE (RD, LD)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:DIANNE
Last Name:SHULTZ
Suffix:
Gender:F
Credentials:RD, LD
Other - Prefix:
Other - First Name:MICHELLE
Other - Middle Name:DIANNE
Other - Last Name:HILDEBRAND
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RD, LD
Mailing Address - Street 1:925 NE 8TH STREET
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73104
Mailing Address - Country:US
Mailing Address - Phone:405-236-3043
Mailing Address - Fax:405-239-2390
Practice Address - Street 1:925 NE 8TH STREET
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73104
Practice Address - Country:US
Practice Address - Phone:405-236-3043
Practice Address - Fax:405-239-2390
Is Sole Proprietor?:No
Enumeration Date:2006-03-23
Last Update Date:2019-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK927133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
OKLD927OtherOKLAHOMA STATE BOARD OF MEDICAL LICENSR