Provider Demographics
NPI:1992008452
Name:SUDDOCK, REBECCA MICHELLE (MS,RD/LD,CSP)
Entity Type:Individual
Prefix:
First Name:REBECCA
Middle Name:MICHELLE
Last Name:SUDDOCK
Suffix:
Gender:F
Credentials:MS,RD/LD,CSP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1200 N PHILLIPS AVE
Mailing Address - Street 2:SUITE 9500
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73104-4600
Mailing Address - Country:US
Mailing Address - Phone:405-271-8001
Mailing Address - Fax:405-271-7866
Practice Address - Street 1:1200 N PHILLIPS AVE
Practice Address - Street 2:SUITE 9500
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73104-4600
Practice Address - Country:US
Practice Address - Phone:405-271-8001
Practice Address - Fax:405-271-7866
Is Sole Proprietor?:Yes
Enumeration Date:2010-12-06
Last Update Date:2010-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK1105133VN1004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133VN1004XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, Pediatric