Provider Demographics
NPI:1396394706
Name:HUMPHREY, SAMANTHA
Entity Type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:
Last Name:HUMPHREY
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 1:328 E HINES HILL RD
Mailing Address - Street 2:
Mailing Address - City:BOSTON HEIGHTS
Mailing Address - State:OH
Mailing Address - Zip Code:44236-1118
Mailing Address - Country:US
Mailing Address - Phone:330-342-5437
Mailing Address - Fax:330-342-9006
Practice Address - Street 1:328 E HINES HILL RD
Practice Address - Street 2:
Practice Address - City:BOSTON HEIGHTS
Practice Address - State:OH
Practice Address - Zip Code:44236-1118
Practice Address - Country:US
Practice Address - Phone:330-342-5437
Practice Address - Fax:330-342-9006
Is Sole Proprietor?:No
Enumeration Date:2019-09-09
Last Update Date:2019-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHAPRN.CNP.025569363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics