Provider Demographics
NPI:1093551459
Name:SMITH, LEAH RENEE (RN)
Entity type:Individual
Prefix:
First Name:LEAH
Middle Name:RENEE
Last Name:SMITH
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:LEAH
Other - Middle Name:RENEE
Other - Last Name:KELLEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN
Mailing Address - Street 1:22772 S 494 RD
Mailing Address - Street 2:
Mailing Address - City:TAHLEQUAH
Mailing Address - State:OK
Mailing Address - Zip Code:74464-1631
Mailing Address - Country:US
Mailing Address - Phone:918-575-4838
Mailing Address - Fax:
Practice Address - Street 1:27753 S WELLING RD
Practice Address - Street 2:
Practice Address - City:WELLING
Practice Address - State:OK
Practice Address - Zip Code:74471-2202
Practice Address - Country:US
Practice Address - Phone:918-316-0576
Practice Address - Fax:918-457-4104
Is Sole Proprietor?:Yes
Enumeration Date:2024-07-05
Last Update Date:2024-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK218416163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse