Provider Demographics
NPI:1114222809
Name:SMITH, JOHNNY R (RN)
Entity Type:Individual
Prefix:
First Name:JOHNNY
Middle Name:R
Last Name:SMITH
Suffix:
Gender:M
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2301 S EIGHT TRIBES TRL
Mailing Address - Street 2:PO BOX 1498
Mailing Address - City:MIAMI
Mailing Address - State:OK
Mailing Address - Zip Code:74354-1009
Mailing Address - Country:US
Mailing Address - Phone:918-542-1655
Mailing Address - Fax:
Practice Address - Street 1:2301 S EIGHT TRIBES TRL
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:OK
Practice Address - Zip Code:74354-1009
Practice Address - Country:US
Practice Address - Phone:918-542-1655
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-01-11
Last Update Date:2011-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKR0074090163WD0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WD0400XNursing Service ProvidersRegistered NurseDiabetes Educator