Provider Demographics
NPI:1093479974
Name:FANT, SAMARA DANIELLE
Entity Type:Individual
Prefix:
First Name:SAMARA
Middle Name:DANIELLE
Last Name:FANT
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 1:942 CAMERON AVE
Mailing Address - Street 2:
Mailing Address - City:YOUNGSTOWN
Mailing Address - State:OH
Mailing Address - Zip Code:44502-2104
Mailing Address - Country:US
Mailing Address - Phone:330-507-3614
Mailing Address - Fax:
Practice Address - Street 1:942 CAMERON AVE
Practice Address - Street 2:
Practice Address - City:YOUNGSTOWN
Practice Address - State:OH
Practice Address - Zip Code:44502-2104
Practice Address - Country:US
Practice Address - Phone:330-507-3614
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-26
Last Update Date:2021-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH376K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes376K00000XNursing Service Related ProvidersNurse's AideGroup - Single Specialty