Healthcare Provider Details

I. General information

NPI: 1659280501
Provider Name (Legal Business Name): PERSONALIZED LIFESTYLE NUTRITION, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/04/2026
Last Update Date: 09/04/2026
Certification Date: 09/04/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1125 N PORTER AVE STE 305
NORMAN OK
73071-6446
US

IV. Provider business mailing address

4232 HACKNEY WICK RD
NORMAN OK
73072-9790
US

V. Phone/Fax

Practice location:
  • Phone: 405-245-9475
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133NN1002X
TaxonomyNutrition Education Nutritionist
License Number
License Number State

VIII. Authorized Official

Name: TAMRA KEYS WINSTON
Title or Position: CREDENTIALING SPECIALIST
Credential:
Phone: 281-790-0188