Provider Demographics
NPI:1588389225
Name:GIBBS, MIKALA RENEE (RD/LD)
Entity type:Individual
Prefix:
First Name:MIKALA
Middle Name:RENEE
Last Name:GIBBS
Suffix:
Gender:F
Credentials:RD/LD
Other - Prefix:
Other - First Name:MIKALA
Other - Middle Name:RENEE
Other - Last Name:GARLETT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3520 N VIRGINIA AVE
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73118-3012
Mailing Address - Country:US
Mailing Address - Phone:405-919-0327
Mailing Address - Fax:
Practice Address - Street 1:5472 MAIN ST STE 101
Practice Address - Street 2:
Practice Address - City:DEL CITY
Practice Address - State:OK
Practice Address - Zip Code:73115-5524
Practice Address - Country:US
Practice Address - Phone:405-622-3699
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-10-05
Last Update Date:2022-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK2747133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered