Provider Demographics
NPI:1689851628
Name:BUSTILLOS, BRENDA D (MS, RD, LD)
Entity Type:Individual
Prefix:MS
First Name:BRENDA
Middle Name:D
Last Name:BUSTILLOS
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:PO BOX 131
Mailing Address - Street 2:
Mailing Address - City:MEDICINE PARK
Mailing Address - State:OK
Mailing Address - Zip Code:73557-0131
Mailing Address - Country:US
Mailing Address - Phone:580-458-3055
Mailing Address - Fax:580-458-2846
Practice Address - Street 1:4301 MOW-WAY ROAD (MCUA-NCD)
Practice Address - Street 2:CDR USAMEDDAC
Practice Address - City:FORT SILL
Practice Address - State:OK
Practice Address - Zip Code:73503-6300
Practice Address - Country:US
Practice Address - Phone:580-458-3055
Practice Address - Fax:580-458-2846
Is Sole Proprietor?:No
Enumeration Date:2008-01-22
Last Update Date:2008-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXDT80151133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered