Basic Information
| Provider Information | |||||||||
| NPI: | 1588939714 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SMALL | ||||||||
| FirstName: | AMANDA | ||||||||
| MiddleName: | LEIGH | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | NP | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | JOHNSTON | ||||||||
| OtherFirstName: | AMANDA | ||||||||
| OtherMiddleName: | LEIGH | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 7333 S TELLER CT | ||||||||
| Address2: | |||||||||
| City: | LITTLETON | ||||||||
| State: | CO | ||||||||
| PostalCode: | 801284763 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7703352242 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 7700 S BROADWAY | ||||||||
| Address2: | |||||||||
| City: | LITTLETON | ||||||||
| State: | CO | ||||||||
| PostalCode: | 801222602 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3037308900 | ||||||||
| FaxNumber: | 3037387755 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/21/2012 | ||||||||
| LastUpdateDate: | 08/30/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 08/30/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | RN199065 | GA | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 363LF0000X | APN.0991549-NP | CO | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 363LA2100X | APN.0991549-NP | CO | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Acute Care |
ID Information
| ID | Type | State | Issuer | Description | 57779732 | 05 | CO | MEDICAID |