Provider Demographics
NPI:1831807205
Name:PHELPS, MARK
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:PHELPS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:901 12TH AVE NW
Mailing Address - Street 2:
Mailing Address - City:ARDMORE
Mailing Address - State:OK
Mailing Address - Zip Code:73401-5734
Mailing Address - Country:US
Mailing Address - Phone:580-319-7305
Mailing Address - Fax:
Practice Address - Street 1:901 12TH AVE NW
Practice Address - Street 2:
Practice Address - City:ARDMORE
Practice Address - State:OK
Practice Address - Zip Code:73401-5734
Practice Address - Country:US
Practice Address - Phone:580-319-7305
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-11-14
Last Update Date:2022-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133NN1002XDietary & Nutritional Service ProvidersNutritionistNutrition, Education