Healthcare Provider Details

I. General information

NPI: 1144857517
Provider Name (Legal Business Name): REBECCA PORTER MS, RD, CSP, LD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: BECKY PORTER

II. Dates (important events)

Enumeration Date: 03/25/2020
Last Update Date: 03/25/2020
Certification Date: 03/25/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6161 S YALE AVE
TULSA OK
74136-1902
US

IV. Provider business mailing address

2853 E 35TH PL
TULSA OK
74105-2927
US

V. Phone/Fax

Practice location:
  • Phone: 918-494-2200
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133VN1004X
TaxonomyPediatric Nutrition Registered Dietitian
License Number801
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: