Healthcare Provider Details

I. General information

NPI: 1104191931
Provider Name (Legal Business Name): SUZANNE E GAULDIN LD/RD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/12/2012
Last Update Date: 11/04/2024
Certification Date: 11/04/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12906 E 106TH ST N
OWASSO OK
74055-5909
US

IV. Provider business mailing address

12906 E 106TH ST N
OWASSO OK
74055-5909
US

V. Phone/Fax

Practice location:
  • Phone: 918-698-0965
  • Fax:
Mailing address:
  • Phone: 918-698-0965
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133VN1006X
TaxonomyMetabolic Nutrition Registered Dietitian
License Number764
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: