Healthcare Provider Details

I. General information

NPI: 1528435922
Provider Name (Legal Business Name): CHARLOTTE SMITH B.A.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/01/2015
Last Update Date: 09/01/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4122 W 55TH PL SUITES 207/208
TULSA OK
74107-9108
US

IV. Provider business mailing address

PO BOX 702504
TULSA OK
74170-2504
US

V. Phone/Fax

Practice location:
  • Phone: 918-791-0026
  • Fax: 918-791-0043
Mailing address:
  • Phone: 918-791-0026
  • Fax: 918-791-0043

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number00000
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: