Provider Demographics
NPI:1174382295
Name:CASANOVA, SHALENA
Entity type:Individual
Prefix:
First Name:SHALENA
Middle Name:
Last Name:CASANOVA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3415 E FAIRMONT PL
Mailing Address - Street 2:
Mailing Address - City:BROKEN ARROW
Mailing Address - State:OK
Mailing Address - Zip Code:74014-8860
Mailing Address - Country:US
Mailing Address - Phone:918-313-4640
Mailing Address - Fax:
Practice Address - Street 1:6128 E 38TH ST
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74135-5832
Practice Address - Country:US
Practice Address - Phone:918-313-4640
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-03-19
Last Update Date:2024-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133NN1002XDietary & Nutritional Service ProvidersNutritionistNutrition, Education