Provider Demographics
NPI:1770047474
Name:SMITH, AMANDA M
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:M
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 1:9200 W. WISCONSIN AVE
Mailing Address - Street 2:5TH FLOOR PAVILLION, 515 AP
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53226
Mailing Address - Country:US
Mailing Address - Phone:414-805-9959
Mailing Address - Fax:
Practice Address - Street 1:9200 W. WISCONSIN AVE
Practice Address - Street 2:5TH FLOOR PAVILLION, 515 AP
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53226
Practice Address - Country:US
Practice Address - Phone:414-805-9959
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-27
Last Update Date:2020-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI9012363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1770047474Medicaid