Provider Demographics
NPI:1851829865
Name:MIRACLE, SARAH JANE (RDN,LD)
Entity Type:Individual
Prefix:
First Name:SARAH
Middle Name:JANE
Last Name:MIRACLE
Suffix:
Gender:F
Credentials:RDN,LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:409 S 14TH PL
Mailing Address - Street 2:
Mailing Address - City:ADA
Mailing Address - State:OK
Mailing Address - Zip Code:74820-7137
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:409 S 14TH PL
Practice Address - Street 2:
Practice Address - City:ADA
Practice Address - State:OK
Practice Address - Zip Code:74820-7137
Practice Address - Country:US
Practice Address - Phone:580-421-5970
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-06-03
Last Update Date:2017-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK470133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered