Provider Demographics
NPI:1497519912
Name:SMITH, AMANDA M
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:M
Last Name:SMITH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:AMANDA
Other - Middle Name:M
Other - Last Name:MITCHELL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:31652 S GAYLENE DR
Mailing Address - Street 2:
Mailing Address - City:INOLA
Mailing Address - State:OK
Mailing Address - Zip Code:74036-5814
Mailing Address - Country:US
Mailing Address - Phone:918-864-6822
Mailing Address - Fax:
Practice Address - Street 1:31652 S GAYLENE DR
Practice Address - Street 2:
Practice Address - City:INOLA
Practice Address - State:OK
Practice Address - Zip Code:74036-5814
Practice Address - Country:US
Practice Address - Phone:918-864-6822
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-02-07
Last Update Date:2024-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKR0124662163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse