Provider Demographics
NPI:1760230155
Name:SMITH, SUSAN RAYLYNN
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:RAYLYNN
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 1:415 KIMBERLY DR APT 2
Mailing Address - Street 2:
Mailing Address - City:ELK CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73644-4800
Mailing Address - Country:US
Mailing Address - Phone:580-277-5552
Mailing Address - Fax:
Practice Address - Street 1:210 N BROADWAY ST
Practice Address - Street 2:
Practice Address - City:SAYRE
Practice Address - State:OK
Practice Address - Zip Code:73662-2946
Practice Address - Country:US
Practice Address - Phone:580-243-9574
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-05-09
Last Update Date:2024-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist