Provider Demographics
NPI:1386626950
Name:SMITH, KATHLEEN (ARNP)
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:
Last Name:SMITH
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4401 W MEMORIAL RD
Mailing Address - Street 2:STE 121
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73134-1785
Mailing Address - Country:US
Mailing Address - Phone:405-751-4664
Mailing Address - Fax:405-749-4557
Practice Address - Street 1:1011 14TH AVE NW
Practice Address - Street 2:ER DEPT
Practice Address - City:ARDMORE
Practice Address - State:OK
Practice Address - Zip Code:73401-1828
Practice Address - Country:US
Practice Address - Phone:800-749-4560
Practice Address - Fax:405-749-4557
Is Sole Proprietor?:No
Enumeration Date:2005-11-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKR59329363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100150540AMedicaid
OK242611808Medicare ID - Type Unspecified
OK244531105Medicare ID - Type Unspecified
OKS98366Medicare UPIN
OK244531106Medicare ID - Type Unspecified