Provider Demographics
NPI:1316761950
Name:SMITH, KLOEY LEE
Entity type:Individual
Prefix:
First Name:KLOEY
Middle Name:LEE
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 1:419 HARRIS RD
Mailing Address - Street 2:
Mailing Address - City:HAWORTH
Mailing Address - State:OK
Mailing Address - Zip Code:74740-5138
Mailing Address - Country:US
Mailing Address - Phone:918-974-9264
Mailing Address - Fax:
Practice Address - Street 1:701 US-70 EAST
Practice Address - Street 2:
Practice Address - City:KINGSTON
Practice Address - State:OK
Practice Address - Zip Code:73439
Practice Address - Country:US
Practice Address - Phone:580-624-6070
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-11-11
Last Update Date:2025-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
OK5455363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program