Healthcare Provider Details

I. General information

NPI: 1205583135
Provider Name (Legal Business Name): PAULA MARIE HUNNICUTT CHN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/10/2022
Last Update Date: 02/13/2023
Certification Date: 02/13/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

23127 E 930 RD
CUSTER CITY OK
73639-3900
US

IV. Provider business mailing address

23127 E 930 RD
CUSTER CITY OK
73639-3900
US

V. Phone/Fax

Practice location:
  • Phone: 580-309-2828
  • Fax:
Mailing address:
  • Phone: 580-309-2828
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133NN1002X
TaxonomyNutrition Education Nutritionist
License Number14772
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: