Provider Demographics
NPI:1508121658
Name:SMITH, AMANDA A (MSN, APRN)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:A
Last Name:SMITH
Suffix:
Gender:F
Credentials:MSN, APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 3755
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68103-0755
Mailing Address - Country:US
Mailing Address - Phone:402-354-2100
Mailing Address - Fax:402-354-2155
Practice Address - Street 1:320 EBAUGH ST
Practice Address - Street 2:
Practice Address - City:GLENWOOD
Practice Address - State:IA
Practice Address - Zip Code:51534-1811
Practice Address - Country:US
Practice Address - Phone:712-527-5204
Practice Address - Fax:712-527-9346
Is Sole Proprietor?:No
Enumeration Date:2012-07-05
Last Update Date:2015-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE111374363LF0000X
IAA117293363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA1508121658Medicaid
NE47068731777Medicaid
NE47068731712Medicaid
IA1508121658Medicaid
IA075120019Medicare PIN