Provider Demographics
NPI:1548736937
Name:SMITH, AMY MARIE (LAC)
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:MARIE
Last Name:SMITH
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1409 GREY ROCK DR
Mailing Address - Street 2:
Mailing Address - City:FORT COLLINS
Mailing Address - State:CO
Mailing Address - Zip Code:80524-9452
Mailing Address - Country:US
Mailing Address - Phone:720-300-5615
Mailing Address - Fax:
Practice Address - Street 1:1121 W PROSPECT RD STE B
Practice Address - Street 2:
Practice Address - City:FORT COLLINS
Practice Address - State:CO
Practice Address - Zip Code:80526-5623
Practice Address - Country:US
Practice Address - Phone:970-377-0918
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-23
Last Update Date:2018-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO2370171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist