Healthcare Provider Details

I. General information

NPI: 1972941110
Provider Name (Legal Business Name): ELIZABETH A SISNEROS RD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: ELIZABETH A BOLLINGER

II. Dates (important events)

Enumeration Date: 06/10/2013
Last Update Date: 06/03/2020
Certification Date: 06/03/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4200 W MEMORIAL RD STE 508
OKLAHOMA CITY OK
73120-8359
US

IV. Provider business mailing address

PO BOX 5980
LUBBOCK TX
79408-5980
US

V. Phone/Fax

Practice location:
  • Phone: 405-755-7561
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number2443
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: