Provider Demographics
NPI:1184260846
Name:STANBROUGH, CYNTHIA
Entity type:Individual
Prefix:
First Name:CYNTHIA
Middle Name:
Last Name:STANBROUGH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10501 ALBERT ST
Mailing Address - Street 2:
Mailing Address - City:YUKON
Mailing Address - State:OK
Mailing Address - Zip Code:73099-8348
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4200 W MEMORIAL RD STE 508
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73120-8359
Practice Address - Country:US
Practice Address - Phone:405-755-7561
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-11-18
Last Update Date:2019-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK720133VN1005X, 133VN1006X, 133VN1201X, 133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
No133VN1005XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, Renal
No133VN1006XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, Metabolic
No133VN1201XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, Obesity and Weight Management