Provider Demographics
NPI:1447875471
Name:KOEMEL, NICHOLAS A (MS, RD)
Entity type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:A
Last Name:KOEMEL
Suffix:
Gender:M
Credentials:MS, RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3724 W 32ND AVE
Mailing Address - Street 2:
Mailing Address - City:STILLWATER
Mailing Address - State:OK
Mailing Address - Zip Code:74074-1724
Mailing Address - Country:US
Mailing Address - Phone:405-880-0969
Mailing Address - Fax:
Practice Address - Street 1:3724 W 32ND AVE
Practice Address - Street 2:
Practice Address - City:STILLWATER
Practice Address - State:OK
Practice Address - Zip Code:74074-1724
Practice Address - Country:US
Practice Address - Phone:405-880-0969
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-16
Last Update Date:2020-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered