Provider Demographics
NPI:1437596962
Name:SMITH, AMY NICHOLE (PA-C)
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:NICHOLE
Last Name:SMITH
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:AMY
Other - Middle Name:NICHOLE
Other - Last Name:CAMPBELL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 4046
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65808-4046
Mailing Address - Country:US
Mailing Address - Phone:417-269-7728
Mailing Address - Fax:417-269-7729
Practice Address - Street 1:3801 S NATIONAL AVE
Practice Address - Street 2:5TH FLOOR
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65807-5210
Practice Address - Country:US
Practice Address - Phone:417-269-7728
Practice Address - Fax:417-269-7729
Is Sole Proprietor?:No
Enumeration Date:2013-05-23
Last Update Date:2013-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2013012269363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant