Basic Information
| Provider Information | |||||||||
| NPI: | 1821395666 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | TYNON | ||||||||
| FirstName: | MARCIA | ||||||||
| MiddleName: | D. | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | L.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | MCGEE | ||||||||
| OtherFirstName: | MARCIA | ||||||||
| OtherMiddleName: | D. | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1001 E 18TH ST | ||||||||
| Address2: | |||||||||
| City: | GROVE | ||||||||
| State: | OK | ||||||||
| PostalCode: | 743442907 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9187864461 | ||||||||
| FaxNumber: | 9187873645 | ||||||||
| Practice Location | |||||||||
| Address1: | 1001 E 18TH ST | ||||||||
| Address2: | |||||||||
| City: | GROVE | ||||||||
| State: | OK | ||||||||
| PostalCode: | 743442907 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9187864461 | ||||||||
| FaxNumber: | 9187873645 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/14/2011 | ||||||||
| LastUpdateDate: | 02/14/2011 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialNameSuffix: | |||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 133V00000X | 1428 | OK | Y | Dietary & Nutritional Service Providers | Dietitian, Registered |
No ID Information.