Provider Demographics
NPI:1841213162
Name:DEAN, ERICA RAE (RD/LD)
Entity Type:Individual
Prefix:MS
First Name:ERICA
Middle Name:RAE
Last Name:DEAN
Suffix:
Gender:F
Credentials:RD/LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:101 S MOORE AVE
Mailing Address - Street 2:
Mailing Address - City:CLAREMORE
Mailing Address - State:OK
Mailing Address - Zip Code:74017-5047
Mailing Address - Country:US
Mailing Address - Phone:918-342-6555
Mailing Address - Fax:918-342-6677
Practice Address - Street 1:101 S MOORE AVE
Practice Address - Street 2:
Practice Address - City:CLAREMORE
Practice Address - State:OK
Practice Address - Zip Code:74017-5047
Practice Address - Country:US
Practice Address - Phone:918-342-6555
Practice Address - Fax:918-342-6677
Is Sole Proprietor?:No
Enumeration Date:2006-07-26
Last Update Date:2012-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK1241133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK248523703Medicare PIN