Provider Demographics
NPI:1104290071
Name:SMALL, AMANDA DAWN (APRN)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:DAWN
Last Name:SMALL
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6600 S YALE AVE
Mailing Address - Street 2:SUITE 1400
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74136-3347
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6585 S YALE AVE
Practice Address - Street 2:SUITE 1150
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74136-8384
Practice Address - Country:US
Practice Address - Phone:918-494-9425
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-11-16
Last Update Date:2016-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK92576363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner