Provider Demographics
NPI:1336686708
Name:ANDERSON, SAMANTHA BETH (CNP)
Entity Type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:BETH
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1205 MCLAIN ST
Mailing Address - Street 2:
Mailing Address - City:NEWPORT
Mailing Address - State:AR
Mailing Address - Zip Code:72112-3533
Mailing Address - Country:US
Mailing Address - Phone:870-523-8911
Mailing Address - Fax:870-512-3455
Practice Address - Street 1:1205 MCLAIN ST
Practice Address - Street 2:
Practice Address - City:NEWPORT
Practice Address - State:AR
Practice Address - Zip Code:72112-3533
Practice Address - Country:US
Practice Address - Phone:870-523-8911
Practice Address - Fax:870-512-3455
Is Sole Proprietor?:No
Enumeration Date:2017-01-24
Last Update Date:2021-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR216639363LF0000X
ARS002305364SA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No364SA2200XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR218616758Medicaid