Healthcare Provider Details

I. General information

NPI: 1225795206
Provider Name (Legal Business Name): AMANDA MICHELLE SMITH CSFA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/24/2021
Last Update Date: 11/24/2021
Certification Date: 11/11/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

520 S EAGLE RD
MERIDIAN ID
83642-6351
US

IV. Provider business mailing address

25125 LOWER PLEASANT RIDGE RD
WILDER ID
83676-5511
US

V. Phone/Fax

Practice location:
  • Phone: 208-706-2161
  • Fax:
Mailing address:
  • Phone: 208-249-6992
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code246ZC0007X
TaxonomySurgical Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: