Provider Demographics
NPI:1609546829
Name:DUNHAM, KRYSTAL (MS, RDN, LD)
Entity Type:Individual
Prefix:
First Name:KRYSTAL
Middle Name:
Last Name:DUNHAM
Suffix:
Gender:F
Credentials:MS, RDN, LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8211 E REGAL PL STE 100
Mailing Address - Street 2:PMB 704
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74133-7181
Mailing Address - Country:US
Mailing Address - Phone:918-212-6235
Mailing Address - Fax:918-245-2530
Practice Address - Street 1:8211 E REGAL PL STE 100
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74133-7181
Practice Address - Country:US
Practice Address - Phone:918-212-6235
Practice Address - Fax:918-273-6660
Is Sole Proprietor?:No
Enumeration Date:2021-09-18
Last Update Date:2023-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR10226937133V00000X
TXDT87200133V00000X
OKLD2630133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered