Provider Demographics
NPI:1558727602
Name:BLACKSTOCK, MORGAN (MS, RD/LD)
Entity Type:Individual
Prefix:
First Name:MORGAN
Middle Name:
Last Name:BLACKSTOCK
Suffix:
Gender:F
Credentials:MS, RD/LD
Other - Prefix:
Other - First Name:MORGAN
Other - Middle Name:
Other - Last Name:FOWLER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2307 GORDON COOPER DR
Mailing Address - Street 2:
Mailing Address - City:SHAWNEE
Mailing Address - State:OK
Mailing Address - Zip Code:74801-9007
Mailing Address - Country:US
Mailing Address - Phone:405-395-9303
Mailing Address - Fax:405-395-9305
Practice Address - Street 1:2307 GORDON COOPER DR
Practice Address - Street 2:
Practice Address - City:SHAWNEE
Practice Address - State:OK
Practice Address - Zip Code:74801-9007
Practice Address - Country:US
Practice Address - Phone:405-395-9303
Practice Address - Fax:405-395-9305
Is Sole Proprietor?:No
Enumeration Date:2016-01-05
Last Update Date:2016-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK2101133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered