Provider Demographics
NPI:1710244660
Name:CROSSLEY, NICOLE P (LD)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:P
Last Name:CROSSLEY
Suffix:
Gender:F
Credentials:LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12021 NW 136TH TER
Mailing Address - Street 2:
Mailing Address - City:PIEDMONT
Mailing Address - State:OK
Mailing Address - Zip Code:73078-8959
Mailing Address - Country:US
Mailing Address - Phone:405-863-3622
Mailing Address - Fax:
Practice Address - Street 1:12021 NW 136TH TER
Practice Address - Street 2:
Practice Address - City:PIEDMONT
Practice Address - State:OK
Practice Address - Zip Code:73078-8959
Practice Address - Country:US
Practice Address - Phone:405-863-3622
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-04-17
Last Update Date:2012-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK1813133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered