Provider Demographics
NPI:1386114999
Name:DEDMON, MELODY (RD)
Entity type:Individual
Prefix:
First Name:MELODY
Middle Name:
Last Name:DEDMON
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1401 CLEVELAND ST
Mailing Address - Street 2:
Mailing Address - City:IDABEL
Mailing Address - State:OK
Mailing Address - Zip Code:74745-8005
Mailing Address - Country:US
Mailing Address - Phone:479-234-6433
Mailing Address - Fax:
Practice Address - Street 1:902 E LINCOLN RD
Practice Address - Street 2:
Practice Address - City:IDABEL
Practice Address - State:OK
Practice Address - Zip Code:74745-7337
Practice Address - Country:US
Practice Address - Phone:580-286-2600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-11-27
Last Update Date:2018-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK2370133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered