Provider Demographics
NPI:1700339009
Name:BERRY, BLAKELY KECIA
Entity Type:Individual
Prefix:
First Name:BLAKELY
Middle Name:KECIA
Last Name:BERRY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:BLAKELY
Other - Middle Name:KECIA
Other - Last Name:SHAFER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RD LD
Mailing Address - Street 1:PO BOX 891328
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73189-1328
Mailing Address - Country:US
Mailing Address - Phone:405-703-7300
Mailing Address - Fax:405-703-7333
Practice Address - Street 1:3110 SW 89TH ST
Practice Address - Street 2:STE 200E
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73159-7920
Practice Address - Country:US
Practice Address - Phone:405-703-7300
Practice Address - Fax:405-703-7333
Is Sole Proprietor?:No
Enumeration Date:2016-08-03
Last Update Date:2016-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK2139133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK2139OtherSTATE LICENSE RD LD