Provider Demographics
NPI:1174807168
Name:BOSWELL NUTRITION, PLLC
Entity type:Organization
Organization Name:BOSWELL NUTRITION, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/DIETITIAN
Authorized Official - Prefix:MRS
Authorized Official - First Name:KARA
Authorized Official - Middle Name:RAE
Authorized Official - Last Name:BOSWELL
Authorized Official - Suffix:
Authorized Official - Credentials:MS, RD, LD
Authorized Official - Phone:405-397-6999
Mailing Address - Street 1:13900 STERLINGTON
Mailing Address - Street 2:
Mailing Address - City:EDMOND
Mailing Address - State:OK
Mailing Address - Zip Code:73013-7031
Mailing Address - Country:US
Mailing Address - Phone:405-397-6999
Mailing Address - Fax:405-563-9066
Practice Address - Street 1:400 NW 13TH ST
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73103-3711
Practice Address - Country:US
Practice Address - Phone:405-397-6999
Practice Address - Fax:405-563-9066
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-10-08
Last Update Date:2011-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK1778133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Single Specialty