Healthcare Provider Details

I. General information

NPI: 1033236112
Provider Name (Legal Business Name): KERI DELEIGH HALE R.D. L.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/23/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

700 S TELEPHONE RD
MOORE OK
73160-2502
US

IV. Provider business mailing address

1031 NE 10TH ST
MOORE OK
73160-6840
US

V. Phone/Fax

Practice location:
  • Phone: 405-912-3471
  • Fax:
Mailing address:
  • Phone: 405-209-2509
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number1048
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: