Provider Demographics
NPI:1295228427
Name:SISCO, SAMANTHA BLAIN (NP)
Entity Type:Individual
Prefix:MRS
First Name:SAMANTHA
Middle Name:BLAIN
Last Name:SISCO
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:1417 COUNTY ROAD 750 E
Mailing Address - Street 2:
Mailing Address - City:CARMI
Mailing Address - State:IL
Mailing Address - Zip Code:62821-4830
Mailing Address - Country:US
Mailing Address - Phone:618-384-9533
Mailing Address - Fax:
Practice Address - Street 1:1701 SPRING ST STE B
Practice Address - Street 2:
Practice Address - City:JEFFERSONVLLE
Practice Address - State:IN
Practice Address - Zip Code:47130-2930
Practice Address - Country:US
Practice Address - Phone:812-284-2273
Practice Address - Fax:812-284-2279
Is Sole Proprietor?:No
Enumeration Date:2018-06-12
Last Update Date:2022-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN28202222A163W00000X
IN71012972A363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN71012972AOtherLICENSE NUMBER