Provider Demographics
NPI:1992324834
Name:SMITH, AMANDA ROSE (FNP-C)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:ROSE
Last Name:SMITH
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 490
Mailing Address - Street 2:
Mailing Address - City:MCCOMB
Mailing Address - State:MS
Mailing Address - Zip Code:39649-0490
Mailing Address - Country:US
Mailing Address - Phone:601-249-2701
Mailing Address - Fax:
Practice Address - Street 1:1167 E BROAD ST
Practice Address - Street 2:
Practice Address - City:MONTICELLO
Practice Address - State:MS
Practice Address - Zip Code:39654-7682
Practice Address - Country:US
Practice Address - Phone:601-587-1433
Practice Address - Fax:601-587-1625
Is Sole Proprietor?:No
Enumeration Date:2020-04-10
Last Update Date:2020-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS903907363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily