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General NPI Number Information
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NPI Number | 1174469340
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Entity Type | Individual
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Provider Name | KELLY LYNN CRUNK RD
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Gender | Female
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Dates
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Enumeration Date | 04/28/2026
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Last Update Date | 04/28/2026
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Provider Practice Location Address
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Address Line | 3601 OLD GEORGETOWNE RD
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City | EDMOND
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State | OK
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Zip | 73013-0807
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Country | US
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Telephone | 904-613-3836
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Fax |
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Provider Business Mailing Address
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Address Line | 3601 OLD GEORGETOWNE RD
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City | EDMOND
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State | OK
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Zip | 73013-0807
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Country | US
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Telephone | 904-613-3836
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 133VN1005X
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Taxonomy Name | Renal Nutrition Registered Dietitian
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License Number | 522
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License Number State | OK
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