Healthcare Provider Details

I. General information

NPI: 1861610503
Provider Name (Legal Business Name): CHRISTIE LEA COGGBURN RD, LD,CSR
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/20/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 S BLISS AVE
TAHLEQUAH OK
74464-2512
US

IV. Provider business mailing address

118 EUBANKS
TAHLEQUAH OK
74464-8841
US

V. Phone/Fax

Practice location:
  • Phone: 918-458-3178
  • Fax:
Mailing address:
  • Phone: 918-431-1515
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133VN1005X
TaxonomyRenal Nutrition Registered Dietitian
License NumberLD982
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: