MEDICARE: MS. ELIZABETH CANDACE HUBBARD RD, LD

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	2275	OK

General Provider Information

NPI Number	:	1518660810
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. ELIZABETH CANDACE HUBBARD RD, LD

Provider Business Mailing Address
First Line	:	9900 W HIGHWAY 66 APT 1610
Second Line	:
City	:	YUKON
State	:	OK
Zip	:	73099-0020
Country	:	US
Telephone Number	:	240-271-4021
Fax Number	:

Provider Business Practice Location Address
First Line	:	7800 NW 23RD ST
Second Line	:
City	:	BETHANY
State	:	OK
Zip	:	73008-4948
Country	:	US
Telephone Number	:	405-495-8606
Fax Number	:	405-495-4356

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

Provider Enumeration Date	:	03/24/2023
Last Update Date	:	03/24/2023

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