Provider Demographics
NPI:1245829381
Name:BAXTER, BONITA NICHELLE (RD)
Entity type:Individual
Prefix:
First Name:BONITA
Middle Name:NICHELLE
Last Name:BAXTER
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11001 SE 95TH ST
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73165-9200
Mailing Address - Country:US
Mailing Address - Phone:405-834-0296
Mailing Address - Fax:
Practice Address - Street 1:11001 SE 95TH ST
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73165-9200
Practice Address - Country:US
Practice Address - Phone:405-834-0296
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-13
Last Update Date:2021-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK921133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered