Provider Demographics
NPI:1750923637
Name:HUMPHREY, TANYA R (BS, NDTR)
Entity type:Individual
Prefix:MRS
First Name:TANYA
Middle Name:R
Last Name:HUMPHREY
Suffix:
Gender:F
Credentials:BS, NDTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12 BUFFALO PL
Mailing Address - Street 2:
Mailing Address - City:BURNEYVILLE
Mailing Address - State:OK
Mailing Address - Zip Code:73430-2136
Mailing Address - Country:US
Mailing Address - Phone:580-276-9003
Mailing Address - Fax:
Practice Address - Street 1:12 BUFFALO PL
Practice Address - Street 2:
Practice Address - City:BURNEYVILLE
Practice Address - State:OK
Practice Address - Zip Code:73430-2136
Practice Address - Country:US
Practice Address - Phone:580-276-9003
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-10-12
Last Update Date:2019-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes136A00000XDietary & Nutritional Service ProvidersDietetic Technician, Registered