Provider Demographics
NPI:1497161574
Name:SMITH, KATRINA
Entity Type:Individual
Prefix:
First Name:KATRINA
Middle Name:
Last Name:SMITH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:600 N GRAND AVE
Mailing Address - Street 2:
Mailing Address - City:THLEQUAH,
Mailing Address - State:OK
Mailing Address - Zip Code:74464
Mailing Address - Country:US
Mailing Address - Phone:405-413-1614
Mailing Address - Fax:
Practice Address - Street 1:600 N GRAND AVE
Practice Address - Street 2:
Practice Address - City:THLEQUAH,
Practice Address - State:OK
Practice Address - Zip Code:74464
Practice Address - Country:US
Practice Address - Phone:405-413-1614
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-07-09
Last Update Date:2014-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator