Provider Demographics
NPI:1043965924
Name:REILLY, SAMANTHA R (NP)
Entity Type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:R
Last Name:REILLY
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:SAMANTHA
Other - Middle Name:R
Other - Last Name:PETERS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:100 GANNETT DR STE C
Mailing Address - Street 2:
Mailing Address - City:SOUTH PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04106-5900
Mailing Address - Country:US
Mailing Address - Phone:207-828-0361
Mailing Address - Fax:207-874-1483
Practice Address - Street 1:100 FODEN RD EAST, STE 203
Practice Address - Street 2:
Practice Address - City:SOUTH PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04106
Practice Address - Country:US
Practice Address - Phone:207-874-1489
Practice Address - Fax:207-523-8590
Is Sole Proprietor?:No
Enumeration Date:2022-02-18
Last Update Date:2024-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MECNP202220363L00000X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner