Healthcare Provider Details

I. General information

NPI: 1679259964
Provider Name (Legal Business Name): CRYSTAL DAWN DISHMAN IBCLC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/22/2023
Last Update Date: 06/22/2023
Certification Date: 06/22/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 ROCKEFELLER DR
MUSKOGEE OK
74401-5075
US

IV. Provider business mailing address

PO BOX 908
WARNER OK
74469-0908
US

V. Phone/Fax

Practice location:
  • Phone: 918-682-5501
  • Fax:
Mailing address:
  • Phone: 918-781-2022
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174N00000X
TaxonomyLactation Consultant (Non-RN)
License NumberL-311235
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: