Healthcare Provider Details

I. General information

NPI: 1730119223
Provider Name (Legal Business Name): AMY M SMITH CFNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/03/2006
Last Update Date: 11/03/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1020 D A BIGLANE DR
BROOKHAVEN MS
39601-2331
US

IV. Provider business mailing address

PO BOX 1547
SEDALIA MO
65302-1547
US

V. Phone/Fax

Practice location:
  • Phone: 601-823-8000
  • Fax:
Mailing address:
  • Phone: 660-826-5960
  • Fax: 660-826-4852

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberR853291
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: