Provider Demographics
NPI:1730119223
Name:SMITH, AMY M (CFNP)
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:M
Last Name:SMITH
Suffix:
Gender:F
Credentials:CFNP
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 1547
Mailing Address - Street 2:
Mailing Address - City:SEDALIA
Mailing Address - State:MO
Mailing Address - Zip Code:65302-1547
Mailing Address - Country:US
Mailing Address - Phone:660-826-5960
Mailing Address - Fax:660-826-4852
Practice Address - Street 1:1020 D A BIGLANE DR
Practice Address - Street 2:
Practice Address - City:BROOKHAVEN
Practice Address - State:MS
Practice Address - Zip Code:39601-2331
Practice Address - Country:US
Practice Address - Phone:601-823-8000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-03
Last Update Date:2010-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR853291363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS08336062Medicaid
MS500002153Medicare PIN