Healthcare Provider Details

I. General information

NPI: 1275650475
Provider Name (Legal Business Name): PATRICIA RENAE GASKINS-CLARK MS, RD, LD
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

901 N PORTER AVE FOOD & NUTRITION SERVICES
NORMAN OK
73071-6404
US

IV. Provider business mailing address

2716 SW 123RD CT
OKLAHOMA CITY OK
73170-4739
US

V. Phone/Fax

Practice location:
  • Phone: 405-307-2130
  • Fax: 405-307-2120
Mailing address:
  • Phone: 405-691-0444
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License NumberLD517
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: