Provider Demographics
NPI:1881921310
Name:MINNIS, DIANE MARIE (MS, RD/LD)
Entity type:Individual
Prefix:MRS
First Name:DIANE
Middle Name:MARIE
Last Name:MINNIS
Suffix:
Gender:F
Credentials:MS, RD/LD
Other - Prefix:MISS
Other - First Name:DIANE
Other - Middle Name:MARIE
Other - Last Name:CAREL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:835 CLARK DR
Mailing Address - Street 2:
Mailing Address - City:KINGFISHER
Mailing Address - State:OK
Mailing Address - Zip Code:73750-3815
Mailing Address - Country:US
Mailing Address - Phone:405-375-7962
Mailing Address - Fax:405-375-7998
Practice Address - Street 1:1000 KINGFISHER REGIONAL HOSPITAL DR
Practice Address - Street 2:
Practice Address - City:KINGFISHER
Practice Address - State:OK
Practice Address - Zip Code:73750
Practice Address - Country:US
Practice Address - Phone:405-375-7962
Practice Address - Fax:405-375-7998
Is Sole Proprietor?:No
Enumeration Date:2009-11-04
Last Update Date:2009-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK998133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered