Provider Demographics
NPI:1316135213
Name:WARREN HEINZEROTH, CODI REBEKAH (RD LD)
Entity type:Individual
Prefix:MRS
First Name:CODI
Middle Name:REBEKAH
Last Name:WARREN HEINZEROTH
Suffix:
Gender:F
Credentials:RD LD
Other - Prefix:MRS
Other - First Name:CODI
Other - Middle Name:REBEKAH
Other - Last Name:HEINZEROTH
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:RD LD
Mailing Address - Street 1:9478 NE WOLF RD
Mailing Address - Street 2:
Mailing Address - City:ELGIN
Mailing Address - State:OK
Mailing Address - Zip Code:73538-2029
Mailing Address - Country:US
Mailing Address - Phone:580-492-6247
Mailing Address - Fax:
Practice Address - Street 1:4301 MOW WAY ROAD
Practice Address - Street 2:
Practice Address - City:FT SILL
Practice Address - State:OK
Practice Address - Zip Code:73503-6300
Practice Address - Country:US
Practice Address - Phone:580-458-2500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-05
Last Update Date:2007-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK1475133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered