Healthcare Provider Details

I. General information

NPI: 1891362984
Provider Name (Legal Business Name): AMY SMITH
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/07/2021
Last Update Date: 05/20/2026
Certification Date: 05/20/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4103 MATTOX RD APT 8
HOMER AK
99603-7245
US

IV. Provider business mailing address

PO BOX 1813
HOMER AK
99603-1813
US

V. Phone/Fax

Practice location:
  • Phone: 907-202-4448
  • Fax: 907-313-4734
Mailing address:
  • Phone: 907-202-4448
  • Fax: 907-313-4734

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License NumberCERT.
License Number StateAK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: