Provider Demographics
NPI:1275137879
Name:KING, SAMARA LYNETTE
Entity Type:Individual
Prefix:MRS
First Name:SAMARA
Middle Name:LYNETTE
Last Name:KING
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 1:5815 ELAINE DRIVE
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:WV
Mailing Address - Zip Code:25306
Mailing Address - Country:US
Mailing Address - Phone:304-741-5854
Mailing Address - Fax:
Practice Address - Street 1:5815 ELAINE DRIVE
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25306
Practice Address - Country:US
Practice Address - Phone:304-741-5854
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-24
Last Update Date:2020-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant