Healthcare Provider Details

I. General information

NPI: 1114306511
Provider Name (Legal Business Name): HEATHER DORMAN RDN, LD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/19/2015
Last Update Date: 05/09/2024
Certification Date: 05/09/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1011 HONOR HEIGHTS DR
MUSKOGEE OK
74401-1318
US

IV. Provider business mailing address

300 ROCKEFELLER DR
MUSKOGEE OK
74401-5075
US

V. Phone/Fax

Practice location:
  • Phone: 918-577-3287
  • Fax:
Mailing address:
  • Phone: 918-682-5501
  • Fax: 918-684-3390

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number1093785
License Number StateOK
# 2
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number2022
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: