Healthcare Provider Details

I. General information

NPI: 1104925619
Provider Name (Legal Business Name): MARSHA ANN BASNER R.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/21/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3324 E 30TH PL N
TULSA OK
74115-2421
US

IV. Provider business mailing address

3324 E 30TH PL N
TULSA OK
74115-2421
US

V. Phone/Fax

Practice location:
  • Phone: 918-835-8509
  • Fax:
Mailing address:
  • Phone: 918-835-8509
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133NN1002X
TaxonomyNutrition Education Nutritionist
License NumberLD419
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: