Provider Demographics
NPI:1811340524
Name:SMITH, AMBER (CRNA)
Entity type:Individual
Prefix:MRS
First Name:AMBER
Middle Name:
Last Name:SMITH
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5052 N CLINTON ST
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46825-5822
Mailing Address - Country:US
Mailing Address - Phone:260-484-8551
Mailing Address - Fax:260-408-8014
Practice Address - Street 1:1500 N RITTER AVE
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46219-3027
Practice Address - Country:US
Practice Address - Phone:317-355-1411
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-07-18
Last Update Date:2024-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1-126509367500000X
IN28237624A367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered