Provider Demographics
NPI:1255981601
Name:SMITH, DEREK (APRN-CNP)
Entity type:Individual
Prefix:
First Name:DEREK
Middle Name:
Last Name:SMITH
Suffix:
Gender:
Credentials:APRN-CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20 12TH AVE NW
Mailing Address - Street 2:
Mailing Address - City:ARDMORE
Mailing Address - State:OK
Mailing Address - Zip Code:73401-5722
Mailing Address - Country:US
Mailing Address - Phone:580-223-3411
Mailing Address - Fax:580-226-6213
Practice Address - Street 1:1105 MICHELIN RD
Practice Address - Street 2:
Practice Address - City:ARDMORE
Practice Address - State:OK
Practice Address - Zip Code:73401-1085
Practice Address - Country:US
Practice Address - Phone:580-224-8750
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-09-18
Last Update Date:2025-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK102505363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily