Provider Demographics
NPI:1205093093
Name:SMITH, CHERYL L (RD)
Entity type:Individual
Prefix:MS
First Name:CHERYL
Middle Name:L
Last Name:SMITH
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1461 E OMAHA ST
Mailing Address - Street 2:APT. B2
Mailing Address - City:BROKEN ARROW
Mailing Address - State:OK
Mailing Address - Zip Code:74012-0316
Mailing Address - Country:US
Mailing Address - Phone:918-576-4583
Mailing Address - Fax:
Practice Address - Street 1:1461 E OMAHA ST
Practice Address - Street 2:APT. B2
Practice Address - City:BROKEN ARROW
Practice Address - State:OK
Practice Address - Zip Code:74012-0316
Practice Address - Country:US
Practice Address - Phone:918-576-4583
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-19
Last Update Date:2008-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK1467133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered