MEDICARE: BONITA NICHELLE BAXTER RD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	133V00000X	Registered Dietitian	921	OK

General Provider Information

NPI Number	:	1245829381
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BONITA NICHELLE BAXTER RD

Provider Business Mailing Address
First Line	:	11001 SE 95TH ST
Second Line	:
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73165-9200
Country	:	US
Telephone Number	:	405-834-0296
Fax Number	:

Provider Business Practice Location Address
First Line	:	11001 SE 95TH ST
Second Line	:
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73165-9200
Country	:	US
Telephone Number	:	405-834-0296
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/13/2021
Last Update Date	:	01/13/2021

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