Healthcare Provider Details

I. General information

NPI: 1407475890
Provider Name (Legal Business Name): KATHYRN BANDY MS RD LD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/15/2020
Last Update Date: 04/21/2020
Certification Date: 04/21/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10109 E 79TH ST
TULSA OK
74133-4564
US

IV. Provider business mailing address

10109 E 79TH ST
TULSA OK
74133-4564
US

V. Phone/Fax

Practice location:
  • Phone: 918-636-7141
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133VN1301X
TaxonomyOncology Nutrition Registered Dietitian
License Number927863
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: