Provider Demographics
NPI:1013907096
Name:SMITH, AMY PITTLICK (NP)
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:PITTLICK
Last Name:SMITH
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:AMY
Other - Middle Name:DIANA
Other - Last Name:PITTLICK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:FNP
Mailing Address - Street 1:1111 EMERALD BAY RD
Mailing Address - Street 2:
Mailing Address - City:SOUTH LAKE TAHOE
Mailing Address - State:CA
Mailing Address - Zip Code:96150-6207
Mailing Address - Country:US
Mailing Address - Phone:530-543-5659
Mailing Address - Fax:530-541-8723
Practice Address - Street 1:2170 SOUTH AVE
Practice Address - Street 2:
Practice Address - City:SOUTH LAKE TAHOE
Practice Address - State:CA
Practice Address - Zip Code:96150-7026
Practice Address - Country:US
Practice Address - Phone:530-539-6620
Practice Address - Fax:530-539-6617
Is Sole Proprietor?:No
Enumeration Date:2005-10-21
Last Update Date:2018-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVAPRN001842363LF0000X
CA13943363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAQ41391Medicare UPIN
CA1013907096Medicaid
Q41391Medicare UPIN
CAEI729ZMedicare PIN
CAZZZ01597ZMedicare PIN