Provider Demographics
NPI:1750617817
Name:SMITH, AMY (APRN)
Entity type:Individual
Prefix:MRS
First Name:AMY
Middle Name:
Last Name:SMITH
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8 TIMBER HILL RD
Mailing Address - Street 2:
Mailing Address - City:PROSPECT
Mailing Address - State:CT
Mailing Address - Zip Code:06712-1348
Mailing Address - Country:US
Mailing Address - Phone:039-809-8072
Mailing Address - Fax:
Practice Address - Street 1:8 TIMBER HILL RD
Practice Address - Street 2:
Practice Address - City:PROSPECT
Practice Address - State:CT
Practice Address - Zip Code:06712-1348
Practice Address - Country:US
Practice Address - Phone:203-980-9807
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-10-26
Last Update Date:2021-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT4693363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT061470136OtherTAX ID
CT008033774Medicaid