Provider Demographics
NPI:1679566566
Name:FUNDERBURG, KAREN M (MS, RDN/LD)
Entity Type:Individual
Prefix:MRS
First Name:KAREN
Middle Name:M
Last Name:FUNDERBURG
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 1:5601 NW 72ND ST
Mailing Address - Street 2:STE 200
Mailing Address - City:WARR ACRES
Mailing Address - State:OK
Mailing Address - Zip Code:73132-5931
Mailing Address - Country:US
Mailing Address - Phone:405-603-1941
Mailing Address - Fax:405-603-1942
Practice Address - Street 1:5601 NW 72ND ST
Practice Address - Street 2:STE 200
Practice Address - City:WARR ACRES
Practice Address - State:OK
Practice Address - Zip Code:73132-5932
Practice Address - Country:US
Practice Address - Phone:405-603-1941
Practice Address - Fax:405-603-1942
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-25
Last Update Date:2016-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKLD 190133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK238321801Medicare ID - Type Unspecified