Provider Demographics
NPI:1124779129
Name:SMITH, KELLIE DANIELLE (FNP)
Entity type:Individual
Prefix:
First Name:KELLIE
Middle Name:DANIELLE
Last Name:SMITH
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:KELLIE
Other - Middle Name:DANIELLE
Other - Last Name:DICKEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4510 NW 39TH ST
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73122-2503
Mailing Address - Country:US
Mailing Address - Phone:843-929-2590
Mailing Address - Fax:
Practice Address - Street 1:4510 NW 39TH ST
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73122-2503
Practice Address - Country:US
Practice Address - Phone:405-759-4300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-01-12
Last Update Date:2024-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC25717363LP2300X
OK216046363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care