Healthcare Provider Details

I. General information

NPI: 1285768523
Provider Name (Legal Business Name): HOLLY ANN CAMPBELL RD, LD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: HOLLY ANN BUCK

II. Dates (important events)

Enumeration Date: 03/16/2007
Last Update Date: 04/22/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4200 W MEMORIAL RD SUITE 701
OKLAHOMA CITY OK
73120-9350
US

IV. Provider business mailing address

217 W FAIRLANE DR
SAPULPA OK
74066-7074
US

V. Phone/Fax

Practice location:
  • Phone: 405-755-7561
  • Fax: 405-755-7615
Mailing address:
  • Phone: 405-760-7279
  • Fax: 918-512-6974

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number1423
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: