Provider Demographics
NPI:1740933852
Name:SMITH, AMANDA K
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:K
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 1:6336 BUFFALO RD
Mailing Address - Street 2:
Mailing Address - City:WATSON
Mailing Address - State:OK
Mailing Address - Zip Code:74963-5145
Mailing Address - Country:US
Mailing Address - Phone:817-298-7460
Mailing Address - Fax:
Practice Address - Street 1:6336 BUFFALO RD
Practice Address - Street 2:
Practice Address - City:WATSON
Practice Address - State:OK
Practice Address - Zip Code:74963-5145
Practice Address - Country:US
Practice Address - Phone:817-298-7460
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-01-28
Last Update Date:2022-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OKN084156956OtherDL