Healthcare Provider Details

I. General information

NPI: 1316404908
Provider Name (Legal Business Name): HEATHER SMITH
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/01/2019
Last Update Date: 03/01/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

921 NE 13TH ST
OKLAHOMA CITY OK
73104-5007
US

IV. Provider business mailing address

8401 ADDISON WAY
CHOCTAW OK
73020-5300
US

V. Phone/Fax

Practice location:
  • Phone: 405-456-2557
  • Fax:
Mailing address:
  • Phone: 405-209-6439
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WC0200X
TaxonomyCritical Care Medicine Registered Nurse
License Number103757
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: