Healthcare Provider Details

I. General information

NPI: 1992008452
Provider Name (Legal Business Name): REBECCA MICHELLE SUDDOCK MS,RD/LD,CSP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/06/2010
Last Update Date: 12/06/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1200 N PHILLIPS AVE SUITE 9500
OKLAHOMA CITY OK
73104-4600
US

IV. Provider business mailing address

1200 N PHILLIPS AVE SUITE 9500
OKLAHOMA CITY OK
73104-4600
US

V. Phone/Fax

Practice location:
  • Phone: 405-271-8001
  • Fax: 405-271-7866
Mailing address:
  • Phone: 405-271-8001
  • Fax: 405-271-7866

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133VN1004X
TaxonomyPediatric Nutrition Registered Dietitian
License Number1105
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: