Healthcare Provider Details

I. General information

NPI: 1225919814
Provider Name (Legal Business Name): MAUDIE SHANEA KIRKLAND RDN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/10/2025
Last Update Date: 09/10/2025
Certification Date: 09/10/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2091 CALI JO CT UNIT 1
BLANCHARD OK
73010-5324
US

IV. Provider business mailing address

2091 CALI JO CT UNIT 1
BLANCHARD OK
73010-5324
US

V. Phone/Fax

Practice location:
  • Phone: 580-257-1414
  • Fax:
Mailing address:
  • Phone: 580-257-1414
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number3187
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: