Provider Demographics
NPI:1124583885
Name:STATON, SAMANTHA JO LYNETTE
Entity Type:Individual
Prefix:MISS
First Name:SAMANTHA JO
Middle Name:LYNETTE
Last Name:STATON
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 1:28360 CR 280
Mailing Address - Street 2:
Mailing Address - City:CARROLLTON
Mailing Address - State:MO
Mailing Address - Zip Code:64633-8560
Mailing Address - Country:US
Mailing Address - Phone:660-322-1712
Mailing Address - Fax:
Practice Address - Street 1:28360 CR 280
Practice Address - Street 2:
Practice Address - City:CARROLLTON
Practice Address - State:MO
Practice Address - Zip Code:64633-8560
Practice Address - Country:US
Practice Address - Phone:660-322-1712
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-02-07
Last Update Date:2019-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer