Provider Demographics
NPI:1285716803
Name:MONTGOMERY-BUNNEY, CRYSTAL BROOK (MSHA, RD/LD)
Entity type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:BROOK
Last Name:MONTGOMERY-BUNNEY
Suffix:
Gender:F
Credentials:MSHA, RD/LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15336 E 470 RD
Mailing Address - Street 2:
Mailing Address - City:CLAREMORE
Mailing Address - State:OK
Mailing Address - Zip Code:74017-5372
Mailing Address - Country:US
Mailing Address - Phone:918-557-0022
Mailing Address - Fax:
Practice Address - Street 1:15336 E 470 RD
Practice Address - Street 2:
Practice Address - City:CLAREMORE
Practice Address - State:OK
Practice Address - Zip Code:74017-5372
Practice Address - Country:US
Practice Address - Phone:918-557-0022
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK1312133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered