Healthcare Provider Details

I. General information

NPI: 1982747861
Provider Name (Legal Business Name): BETTY JEAN CHUCULATE RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/14/2007
Last Update Date: 12/04/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1265 SOUTH UTICA STE. 100N
TULSA OK
74104-4090
US

IV. Provider business mailing address

1265 1265 SOUTH UTICA STE. 100N
TULSA OK
74104-4090
US

V. Phone/Fax

Practice location:
  • Phone: 918-579-3385
  • Fax:
Mailing address:
  • Phone: 918-579-3385
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133VN1006X
TaxonomyMetabolic Nutrition Registered Dietitian
License Number385
License Number StateOK
# 2
Primary TaxonomyN
Taxonomy Code163WD0400X
TaxonomyDiabetes Educator Registered Nurse
License Number45672
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: