Provider Demographics
NPI:1548449937
Name:SMITH, EDWINNA (ARNP)
Entity type:Individual
Prefix:
First Name:EDWINNA
Middle Name:
Last Name:SMITH
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1901 W 3RD ST STE C
Mailing Address - Street 2:
Mailing Address - City:ELK CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73644-4340
Mailing Address - Country:US
Mailing Address - Phone:580-339-8001
Mailing Address - Fax:580-339-8031
Practice Address - Street 1:1415 WATTS ST
Practice Address - Street 2:
Practice Address - City:SAYRE
Practice Address - State:OK
Practice Address - Zip Code:73662-1310
Practice Address - Country:US
Practice Address - Phone:580-928-2044
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-11-01
Last Update Date:2017-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKR0075474363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200130310AMedicaid
OKOKA105899Medicare PIN