Provider Demographics
NPI:1558601948
Name:FORD, TERRIE DENISE WEAVER (MS RD LD)
Entity Type:Individual
Prefix:MRS
First Name:TERRIE
Middle Name:DENISE WEAVER
Last Name:FORD
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 1:16354 ROSEROCK CIR
Mailing Address - Street 2:
Mailing Address - City:CHOCTAW
Mailing Address - State:OK
Mailing Address - Zip Code:73020-6964
Mailing Address - Country:US
Mailing Address - Phone:405-390-1593
Mailing Address - Fax:
Practice Address - Street 1:16354 ROSEROCK CIR
Practice Address - Street 2:
Practice Address - City:CHOCTAW
Practice Address - State:OK
Practice Address - Zip Code:73020-6964
Practice Address - Country:US
Practice Address - Phone:405-390-1593
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-02-21
Last Update Date:2015-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKLD1901133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK1901OtherLICENSED DIETITIAN
708464OtherREGISTERED DIETITIAN