Provider Demographics
NPI:1336505049
Name:BURGESS, SAMANTHA B (FNP-C)
Entity Type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:B
Last Name:BURGESS
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4815 MACCORKLE AVE SE
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:WV
Mailing Address - Zip Code:25304-1948
Mailing Address - Country:US
Mailing Address - Phone:681-265-1693
Mailing Address - Fax:812-650-9906
Practice Address - Street 1:4815 MACCORKLE AVE SE
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25304-1948
Practice Address - Country:US
Practice Address - Phone:681-265-1693
Practice Address - Fax:681-265-0990
Is Sole Proprietor?:No
Enumeration Date:2016-01-11
Last Update Date:2023-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY3010278363L00000X
NV810074363LF0000X
WVAPRN90027-FNP-BC363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV100519213Medicaid