Provider Demographics
NPI:1174186670
Name:WILLEN, SAMANTHA SHOLEH (PMHNP)
Entity Type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:SHOLEH
Last Name:WILLEN
Suffix:
Gender:F
Credentials:PMHNP
Other - Prefix:
Other - First Name:SAMANTHA
Other - Middle Name:SHOLEH
Other - Last Name:KORDEIE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:7770 N PLACITA SIN MENTIRAS
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85718-1286
Mailing Address - Country:US
Mailing Address - Phone:503-334-6481
Mailing Address - Fax:
Practice Address - Street 1:2311 W ROYAL PALM RD
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85021-4916
Practice Address - Country:US
Practice Address - Phone:602-353-2340
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-04-19
Last Update Date:2019-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ225016363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ553996Medicaid