Provider Demographics
NPI:1275030736
Name:NICOLAI, SAMANTHA M
Entity Type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:M
Last Name:NICOLAI
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 1:148 POST ROAD
Mailing Address - Street 2:
Mailing Address - City:AKIAK
Mailing Address - State:AK
Mailing Address - Zip Code:99552
Mailing Address - Country:US
Mailing Address - Phone:907-765-7125
Mailing Address - Fax:907-765-7856
Practice Address - Street 1:148 POST ROAD
Practice Address - Street 2:
Practice Address - City:AKIAK
Practice Address - State:AK
Practice Address - Zip Code:99552
Practice Address - Country:US
Practice Address - Phone:907-765-7125
Practice Address - Fax:907-765-7856
Is Sole Proprietor?:No
Enumeration Date:2018-04-11
Last Update Date:2018-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker