Provider Demographics
NPI:1821395666
Name:TYNON, MARCIA D (LD)
Entity Type:Individual
Prefix:
First Name:MARCIA
Middle Name:D
Last Name:TYNON
Suffix:
Gender:F
Credentials:LD
Other - Prefix:
Other - First Name:MARCIA
Other - Middle Name:D
Other - Last Name:MCGEE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1001 E 18TH ST
Mailing Address - Street 2:
Mailing Address - City:GROVE
Mailing Address - State:OK
Mailing Address - Zip Code:74344-2907
Mailing Address - Country:US
Mailing Address - Phone:918-786-4461
Mailing Address - Fax:918-787-3645
Practice Address - Street 1:1001 E 18TH ST
Practice Address - Street 2:
Practice Address - City:GROVE
Practice Address - State:OK
Practice Address - Zip Code:74344-2907
Practice Address - Country:US
Practice Address - Phone:918-786-4461
Practice Address - Fax:918-787-3645
Is Sole Proprietor?:No
Enumeration Date:2011-02-14
Last Update Date:2011-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK1428133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered