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NPI Code Detail

MEDICARE: MIKALA RENEE GIBBS RD/LD

MEDICARE: MIKALA RENEE GIBBS 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
1133V00000XRegistered Dietitian2747OK

General Provider Information

NPI Number : 1588389225
Entity Type Code : Individual
Provider Name (Legal Business Name) : MIKALA RENEE GIBBS RD/LD
Provider Business Mailing Address
First Line : 3520 N VIRGINIA AVE
Second Line :
City : OKLAHOMA CITY
State : OK
Zip : 73118-3012
Country : US
Telephone Number : 405-919-0327
Fax Number :
Provider Business Practice Location Address
First Line : 5472 MAIN ST STE 101
Second Line :
City : DEL CITY
State : OK
Zip : 73115-5524
Country : US
Telephone Number : 405-622-3699
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 10/05/2022
Last Update Date : 10/05/2022

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