Healthcare Provider Details

I. General information

NPI: 1164502100
Provider Name (Legal Business Name): NICOLE DIANE FOUNTAIN R.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/16/2006
Last Update Date: 08/27/2026
Certification Date: 08/27/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1801 CHUKKA HINA
DURANT OK
74701-7117
US

IV. Provider business mailing address

1008 W WALKER ST
DENISON TX
75020-2128
US

V. Phone/Fax

Practice location:
  • Phone: 918-567-7000
  • Fax:
Mailing address:
  • Phone: 918-567-7000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number851
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: