Basic Information
| Provider Information | |||||||||
| NPI: | 1790015980 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PURDY | ||||||||
| FirstName: | KRISTIE | ||||||||
| MiddleName: | ANN | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MS, RD/LD | ||||||||
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| Mailing Information | |||||||||
| Address1: | RR 1 BOX 3060 | ||||||||
| Address2: | |||||||||
| City: | CLINTON | ||||||||
| State: | OK | ||||||||
| PostalCode: | 736019303 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5803313458 | ||||||||
| FaxNumber: | 5803232579 | ||||||||
| Practice Location | |||||||||
| Address1: | RR 1 BOX 3060 | ||||||||
| Address2: | |||||||||
| City: | CLINTON | ||||||||
| State: | OK | ||||||||
| PostalCode: | 736019303 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5803313458 | ||||||||
| FaxNumber: | 5803232579 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/11/2010 | ||||||||
| LastUpdateDate: | 05/13/2011 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 133V00000X | 1634 | OK | Y | Dietary & Nutritional Service Providers | Dietitian, Registered |
No ID Information.