Provider Demographics
NPI:1033820089
Name:RYAN, SAMANTHA DANIELLE
Entity Type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:DANIELLE
Last Name:RYAN
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 1:8 EL CAMINO DR
Mailing Address - Street 2:
Mailing Address - City:BUCKHANNON
Mailing Address - State:WV
Mailing Address - Zip Code:26201-6530
Mailing Address - Country:US
Mailing Address - Phone:304-612-7514
Mailing Address - Fax:
Practice Address - Street 1:1123 S DAVIS AVE
Practice Address - Street 2:
Practice Address - City:ELKINS
Practice Address - State:WV
Practice Address - Zip Code:26241-3529
Practice Address - Country:US
Practice Address - Phone:681-378-3908
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-12-12
Last Update Date:2022-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist