Provider Demographics
NPI:1811092729
Name:FLADIE, ANN LOIS (RD, LD)
Entity type:Individual
Prefix:
First Name:ANN
Middle Name:LOIS
Last Name:FLADIE
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 1:102 AGNI WAY
Mailing Address - Street 2:
Mailing Address - City:TAHLEQUAH
Mailing Address - State:OK
Mailing Address - Zip Code:74464-9200
Mailing Address - Country:US
Mailing Address - Phone:918-456-6277
Mailing Address - Fax:
Practice Address - Street 1:1400 E DOWNING ST
Practice Address - Street 2:
Practice Address - City:TAHLEQUAH
Practice Address - State:OK
Practice Address - Zip Code:74464-3324
Practice Address - Country:US
Practice Address - Phone:918-453-2266
Practice Address - Fax:918-453-2196
Is Sole Proprietor?:No
Enumeration Date:2006-09-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK637133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK647795OtherDIETETIC REGISTRATION
OK637OtherMEDICAL LICENSURE