Healthcare Provider Details

I. General information

NPI: 1417860198
Provider Name (Legal Business Name): AMANDA L SMITH FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/24/2026
Last Update Date: 09/24/2026
Certification Date: 09/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12680 OLIVE BLVD
SAINT LOUIS MO
63141-6289
US

IV. Provider business mailing address

8 FAIR ISLE CT
ELLISVILLE MO
63021-4514
US

V. Phone/Fax

Practice location:
  • Phone: 314-251-0541
  • Fax:
Mailing address:
  • Phone: 636-628-1118
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License Number2026040393
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: