Provider Demographics
NPI:1740734565
Name:SMITH, AMANDA NICOLE
Entity Type:Individual
Prefix:MISS
First Name:AMANDA
Middle Name:NICOLE
Last Name:SMITH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:116 MARIAN DR
Mailing Address - Street 2:
Mailing Address - City:SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13219-2423
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:116 MARIAN DR
Practice Address - Street 2:
Practice Address - City:SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13219-2423
Practice Address - Country:US
Practice Address - Phone:315-569-8872
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-10
Last Update Date:2016-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY692607121174400000X
NY692608121174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist