Healthcare Provider Details

I. General information

NPI: 1174889919
Provider Name (Legal Business Name): PAULA NICOLE BROOME R.D./L.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/05/2012
Last Update Date: 04/05/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2307 GORDON COOPER DR
SHAWNEE OK
74801-9007
US

IV. Provider business mailing address

1215 WINDSOR PL
SHAWNEE OK
74804-2347
US

V. Phone/Fax

Practice location:
  • Phone: 405-395-9303
  • Fax: 405-395-9305
Mailing address:
  • Phone: 405-406-5503
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number1774
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: