Healthcare Provider Details

I. General information

NPI: 1659083533
Provider Name (Legal Business Name): ALIXANDRA NICOLE FARISS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/22/2022
Last Update Date: 03/31/2023
Certification Date: 03/31/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5208 W RENO AVE
OKLAHOMA CITY OK
73127-6344
US

IV. Provider business mailing address

4913 W RENO AVE
OKLAHOMA CITY OK
73127-6339
US

V. Phone/Fax

Practice location:
  • Phone: 405-948-4900
  • Fax: 405-948-4933
Mailing address:
  • Phone: 405-948-4900
  • Fax: 405-948-4933

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code133N00000X
TaxonomyNutritionist
License Number860
License Number StateOK
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number860
License Number StateOK
# 3
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number2821
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: