Healthcare Provider Details

I. General information

NPI: 1194960443
Provider Name (Legal Business Name): ANGELINA SUMAN SMITH MS,RD,LD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/15/2008
Last Update Date: 12/15/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9636 N MAY AVE SUITE 279
OKC OK
73120
US

IV. Provider business mailing address

1700 RAQUEL ROAD
EDMOND OK
73003
US

V. Phone/Fax

Practice location:
  • Phone: 405-848-9344
  • Fax:
Mailing address:
  • Phone: 405-330-8141
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133VN1005X
TaxonomyRenal Nutrition Registered Dietitian
License Number1386
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: