MEDICARE: KELLIE DANIELLE SMITH FNP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LP2300X	Primary Care Nurse Practitioner	25717	SC
2	363LF0000X	Family Nurse Practitioner	216046	OK

General Provider Information

NPI Number	:	1124779129
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KELLIE DANIELLE SMITH FNP

Provider Business Mailing Address
First Line	:	4510 NW 39TH ST
Second Line	:
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73122-2503
Country	:	US
Telephone Number	:	843-929-2590
Fax Number	:

Provider Business Practice Location Address
First Line	:	4510 NW 39TH ST
Second Line	:
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73122-2503
Country	:	US
Telephone Number	:	405-759-4300
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/12/2022
Last Update Date	:	09/03/2024

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Directions to “ KELLIE DANIELLE SMITH FNP” Practice Location

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