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General NPI Number Information
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NPI Number | 1942654819
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Entity Type | Individual
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Provider Name | SHAWN IDELL RD, LD
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Gender | Female
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Dates
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Enumeration Date | 04/18/2016
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Last Update Date | 04/18/2016
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Provider Practice Location Address
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Address Line | 1800 W UNIVERSITY BLVD
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City | DURANT
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State | OK
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Zip | 74701-3006
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Country | US
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Telephone | 580-924-3080
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Fax | 580-931-2048
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Provider Business Mailing Address
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Address Line | 1800 W UNIVERSITY BLVD
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City | DURANT
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State | OK
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Zip | 74701-3006
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Country | US
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Telephone | 580-924-3080
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Fax | 580-931-2048
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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 | 133V00000X
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Taxonomy Name | Registered Dietitian
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License Number | 509
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License Number State | OK
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