Provider Demographics
NPI:1760693378
Name:CONWAY, TARA DIANE (MS, RDLD)
Entity Type:Individual
Prefix:MS
First Name:TARA
Middle Name:DIANE
Last Name:CONWAY
Suffix:
Gender:F
Credentials:MS, RDLD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2222 W IOWA AVE
Mailing Address - Street 2:
Mailing Address - City:CHICKASHA
Mailing Address - State:OK
Mailing Address - Zip Code:73018-2738
Mailing Address - Country:US
Mailing Address - Phone:405-224-8111
Mailing Address - Fax:405-222-9561
Practice Address - Street 1:2222 W IOWA AVE
Practice Address - Street 2:
Practice Address - City:CHICKASHA
Practice Address - State:OK
Practice Address - Zip Code:73018-2738
Practice Address - Country:US
Practice Address - Phone:405-224-8111
Practice Address - Fax:405-222-9561
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-24
Last Update Date:2016-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK1187133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK2009201072Medicare PIN