Provider Demographics
NPI:1780121947
Name:CHEATHAM, COURTNEY (RD/LD)
Entity type:Individual
Prefix:MISS
First Name:COURTNEY
Middle Name:
Last Name:CHEATHAM
Suffix:
Gender:F
Credentials:RD/LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14600 N ROCKWELL AVE
Mailing Address - Street 2:#2007
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73142-8200
Mailing Address - Country:US
Mailing Address - Phone:405-226-0348
Mailing Address - Fax:
Practice Address - Street 1:115 W 3RD ST
Practice Address - Street 2:SUITE 800
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74103-3410
Practice Address - Country:US
Practice Address - Phone:918-585-3045
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-01-26
Last Update Date:2017-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK1982133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered