Basic Information
Provider Information | |||||||||
NPI: | 1205067345 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | SMITH | ||||||||
FirstName: | AMANDA | ||||||||
MiddleName: | ERB | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | CRNA | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | ERB | ||||||||
OtherFirstName: | AMANDA | ||||||||
OtherMiddleName: | NOEL | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 11225 | ||||||||
Address2: |   | ||||||||
City: | CHATTANOOGA | ||||||||
State: | TN | ||||||||
PostalCode: | 374012225 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4238925602 | ||||||||
FaxNumber: | 4238925838 | ||||||||
Practice Location | |||||||||
Address1: | 975 E. THIRD STREET | ||||||||
Address2: |   | ||||||||
City: | CHATTANOOGA | ||||||||
State: | TN | ||||||||
PostalCode: | 374032147 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4237787608 | ||||||||
FaxNumber: | 4237782360 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/06/2009 | ||||||||
LastUpdateDate: | 07/28/2010 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | APN14316 | TN | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |   | 163W00000X | RN111076 | TN | N |   | Nursing Service Providers | Registered Nurse |   |
ID Information
ID | Type | State | Issuer | Description | 1515847 | 05 | TN |   | MEDICAID | 815168433A | 05 | GA |   | MEDICAID | 114829 | 05 | AL |   | MEDICAID | 4238807 | 01 | TN | BCBS TN | OTHER |