Provider Demographics
NPI:1386186732
Name:BRANSON, SAMANTHA L (FNP)
Entity Type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:L
Last Name:BRANSON
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:SAMANTHA
Other - Middle Name:L
Other - Last Name:FORD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 955534
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63195-4369
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1101 HIGHWAY K
Practice Address - Street 2:
Practice Address - City:O FALLON
Practice Address - State:MO
Practice Address - Zip Code:63366-8431
Practice Address - Country:US
Practice Address - Phone:636-379-6363
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-11-15
Last Update Date:2020-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2016035534363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily