Provider Demographics
NPI:1679060529
Name:BLAKELY BERRY NUTRITION AND WELLNESS
Entity Type:Organization
Organization Name:BLAKELY BERRY NUTRITION AND WELLNESS
Other - Org Name:BLAKELY BERRY DIETETICS AND WELLNESS
Other - Org Type:Other Name
Authorized Official - Title/Position:REGISTERED DIETITIAN
Authorized Official - Prefix:
Authorized Official - First Name:BLAKELY
Authorized Official - Middle Name:
Authorized Official - Last Name:BERRY
Authorized Official - Suffix:
Authorized Official - Credentials:RDN/LD
Authorized Official - Phone:405-823-1077
Mailing Address - Street 1:1131 NW 38TH ST
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73118-5423
Mailing Address - Country:US
Mailing Address - Phone:405-823-1077
Mailing Address - Fax:
Practice Address - Street 1:6915 N CLASSEN BLVD STE C
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73116-7209
Practice Address - Country:US
Practice Address - Phone:405-823-1077
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-04-17
Last Update Date:2018-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK2139133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK1700339009Medicaid