Healthcare Provider Details

I. General information

NPI: 1740826494
Provider Name (Legal Business Name): SHANNON P CAMPBELL RDN, LD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/18/2019
Last Update Date: 05/12/2021
Certification Date: 05/12/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

717 S HOUSTON AVE STE 400
TULSA OK
74127-9007
US

IV. Provider business mailing address

5310 E 31ST ST FL 13
TULSA OK
74135-5018
US

V. Phone/Fax

Practice location:
  • Phone: 918-382-4600
  • Fax: 918-382-3183
Mailing address:
  • Phone: 918-561-5701
  • Fax: 918-561-1173

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133VN1201X
TaxonomyObesity and Weight Management Nutrition Registered Dietitian
License Number1864
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: