Healthcare Provider Details

I. General information

NPI: 1679566566
Provider Name (Legal Business Name): KAREN M FUNDERBURG MS, RDN/LD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/25/2005
Last Update Date: 12/09/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5601 NW 72ND ST STE 200
WARR ACRES OK
73132-5932
US

IV. Provider business mailing address

5601 NW 72ND ST STE 200
WARR ACRES OK
73132-5931
US

V. Phone/Fax

Practice location:
  • Phone: 405-603-1941
  • Fax: 405-603-1942
Mailing address:
  • Phone: 405-603-1941
  • Fax: 405-603-1942

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License NumberLD 190
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: