Provider Demographics
NPI:1306428222
Name:BROWN, MARQUELLE R (NUTRITIONIST)
Entity type:Individual
Prefix:
First Name:MARQUELLE
Middle Name:R
Last Name:BROWN
Suffix:
Gender:F
Credentials:NUTRITIONIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14530 E 126TH ST N
Mailing Address - Street 2:
Mailing Address - City:COLLINSVILLE
Mailing Address - State:OK
Mailing Address - Zip Code:74021-5663
Mailing Address - Country:US
Mailing Address - Phone:918-645-0427
Mailing Address - Fax:
Practice Address - Street 1:8805 N 145TH EAST AVE STE 105
Practice Address - Street 2:
Practice Address - City:OWASSO
Practice Address - State:OK
Practice Address - Zip Code:74055-8530
Practice Address - Country:US
Practice Address - Phone:918-645-0427
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-21
Last Update Date:2021-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKCNS16907133N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133N00000XDietary & Nutritional Service ProvidersNutritionist