Provider Demographics
NPI:1700575487
Name:SMITH, RYLIE EVAN
Entity type:Individual
Prefix:
First Name:RYLIE
Middle Name:EVAN
Last Name:SMITH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:900 NE 122ND ST APT 2310
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73114-9226
Mailing Address - Country:US
Mailing Address - Phone:580-306-1294
Mailing Address - Fax:
Practice Address - Street 1:1400 E MEMORIAL RD
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73131-1240
Practice Address - Country:US
Practice Address - Phone:405-875-0040
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-05-08
Last Update Date:2024-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK6155235Z00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist