Provider Demographics
NPI:1548340300
Name:SMITH, AMANDA NICHOLE (NP)
Entity type:Individual
Prefix:MS
First Name:AMANDA
Middle Name:NICHOLE
Last Name:SMITH
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1245 WILSHIRE BLVD
Mailing Address - Street 2:STE 703
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90017-4807
Mailing Address - Country:US
Mailing Address - Phone:213-977-7422
Mailing Address - Fax:213-250-8945
Practice Address - Street 1:1245 WILSHIRE BLVD
Practice Address - Street 2:STE 703
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90017-4807
Practice Address - Country:US
Practice Address - Phone:213-977-7422
Practice Address - Fax:213-250-8945
Is Sole Proprietor?:No
Enumeration Date:2006-10-16
Last Update Date:2007-11-09
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CANP16728363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
CARN603014Medicaid
CAWNP16728AMedicare PIN