Provider Demographics
NPI:1003688862
Name:MACIOLEK, SAMANTHA
Entity Type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:
Last Name:MACIOLEK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:225 LAURADELL RD
Mailing Address - Street 2:
Mailing Address - City:ASHLAND
Mailing Address - State:VA
Mailing Address - Zip Code:23005-8217
Mailing Address - Country:US
Mailing Address - Phone:614-905-1755
Mailing Address - Fax:
Practice Address - Street 1:10571 TELEGRAPH RD STE 110
Practice Address - Street 2:
Practice Address - City:GLEN ALLEN
Practice Address - State:VA
Practice Address - Zip Code:23059-4652
Practice Address - Country:US
Practice Address - Phone:804-266-9616
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-10-25
Last Update Date:2023-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024188483363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care