Healthcare Provider Details

I. General information

NPI: 1265367460
Provider Name (Legal Business Name): KENNEDY N LILLARD RD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/17/2026
Last Update Date: 06/17/2026
Certification Date: 06/17/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1413 W 118TH ST S
JENKS OK
74037-4262
US

IV. Provider business mailing address

9290 E 119TH PL S
BIXBY OK
74008-1846
US

V. Phone/Fax

Practice location:
  • Phone: 918-521-9930
  • Fax:
Mailing address:
  • Phone: 918-521-9930
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: