Provider Demographics
NPI:1528435922
Name:SMITH, CHARLOTTE (BA)
Entity type:Individual
Prefix:
First Name:CHARLOTTE
Middle Name:
Last Name:SMITH
Suffix:
Gender:F
Credentials:BA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 702504
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74170-2504
Mailing Address - Country:US
Mailing Address - Phone:918-791-0026
Mailing Address - Fax:918-791-0043
Practice Address - Street 1:4122 W 55TH PL
Practice Address - Street 2:SUITES 207/208
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74107-9108
Practice Address - Country:US
Practice Address - Phone:918-791-0026
Practice Address - Fax:918-791-0043
Is Sole Proprietor?:Yes
Enumeration Date:2015-09-01
Last Update Date:2015-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK00000390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
OKPENDINGMedicaid