Provider Demographics
NPI:1528393253
Name:SMITH, AMANDA KELLEY (NP-C)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:KELLEY
Last Name:SMITH
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:AMANDA
Other - Middle Name:
Other - Last Name:KELLEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:639 HEMLOCK ST
Mailing Address - Street 2:SUITE 200
Mailing Address - City:MACON
Mailing Address - State:GA
Mailing Address - Zip Code:31201-6886
Mailing Address - Country:US
Mailing Address - Phone:478-213-7571
Mailing Address - Fax:
Practice Address - Street 1:639 HEMLOCK ST
Practice Address - Street 2:SUITE 200
Practice Address - City:MACON
Practice Address - State:GA
Practice Address - Zip Code:31201-6886
Practice Address - Country:US
Practice Address - Phone:478-741-5945
Practice Address - Fax:478-743-5890
Is Sole Proprietor?:No
Enumeration Date:2009-10-14
Last Update Date:2009-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN154107NP363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily