Basic Information
| Provider Information | |||||||||
| NPI: | 1548449937 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SMITH | ||||||||
| FirstName: | EDWINNA | ||||||||
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| Credential: | ARNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1901 W 3RD ST STE C | ||||||||
| Address2: | |||||||||
| City: | ELK CITY | ||||||||
| State: | OK | ||||||||
| PostalCode: | 736444340 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5803398001 | ||||||||
| FaxNumber: | 5803398031 | ||||||||
| Practice Location | |||||||||
| Address1: | 1415 WATTS ST | ||||||||
| Address2: | |||||||||
| City: | SAYRE | ||||||||
| State: | OK | ||||||||
| PostalCode: | 736621310 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5809282044 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/01/2007 | ||||||||
| LastUpdateDate: | 10/25/2017 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | R0075474 | OK | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 200130310A | 05 | OK | MEDICAID |