Provider Demographics
NPI:1063039378
Name:RICHARDSON, SAMANTHA DION (NP)
Entity Type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:DION
Last Name:RICHARDSON
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12301 GRAPEFIELD RD
Mailing Address - Street 2:
Mailing Address - City:BASTIAN
Mailing Address - State:VA
Mailing Address - Zip Code:24314-4547
Mailing Address - Country:US
Mailing Address - Phone:276-688-4331
Mailing Address - Fax:276-688-4336
Practice Address - Street 1:12301 GRAPEFIELD RD
Practice Address - Street 2:
Practice Address - City:BASTIAN
Practice Address - State:VA
Practice Address - Zip Code:24314-4547
Practice Address - Country:US
Practice Address - Phone:276-688-4331
Practice Address - Fax:276-688-4336
Is Sole Proprietor?:No
Enumeration Date:2020-07-02
Last Update Date:2022-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209.022272363L00000X
MO2021029431363L00000X
VA0024178357363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner