Provider Demographics
NPI:1225458854
Name:BOTHWELL, SAMANTHA LYNN (RN)
Entity Type:Individual
Prefix:MISS
First Name:SAMANTHA
Middle Name:LYNN
Last Name:BOTHWELL
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3244 W VERA AVE
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53209-2518
Mailing Address - Country:US
Mailing Address - Phone:262-370-1397
Mailing Address - Fax:
Practice Address - Street 1:3244 W VERA AVE
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53209-2518
Practice Address - Country:US
Practice Address - Phone:262-370-1397
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-04-22
Last Update Date:2014-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI168738-30163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse