Basic Information
| Provider Information | |||||||||
| NPI: | 1578550364 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CANANT | ||||||||
| FirstName: | TRACY | ||||||||
| MiddleName: | LOZON | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | RD/LD, CDE | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | CANANT | ||||||||
| OtherFirstName: | TRACY | ||||||||
| OtherMiddleName: | LEE | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | RD/LD, CDE | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 57267 S 725 RD | ||||||||
| Address2: | |||||||||
| City: | COLCORD | ||||||||
| State: | OK | ||||||||
| PostalCode: | 743381123 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9186968806 | ||||||||
| FaxNumber: | 9186968840 | ||||||||
| Practice Location | |||||||||
| Address1: | RR 6 BOX 840 | ||||||||
| Address2: | |||||||||
| City: | STILWELL | ||||||||
| State: | OK | ||||||||
| PostalCode: | 749608703 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9186968806 | ||||||||
| FaxNumber: | 9186968840 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/05/2005 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | X | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 133V00000X | 778 | OK | Y | Dietary & Nutritional Service Providers | Dietitian, Registered |
No ID Information.