Provider Demographics
NPI:1407412406
Name:PRIMM, SAMANTHA JO (FNP)
Entity Type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:JO
Last Name:PRIMM
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1532 W 32ND ST
Mailing Address - Street 2:
Mailing Address - City:JOPLIN
Mailing Address - State:MO
Mailing Address - Zip Code:64804-1607
Mailing Address - Country:US
Mailing Address - Phone:417-347-7009
Mailing Address - Fax:
Practice Address - Street 1:1532 W 32ND ST
Practice Address - Street 2:
Practice Address - City:JOPLIN
Practice Address - State:MO
Practice Address - Zip Code:64804-1607
Practice Address - Country:US
Practice Address - Phone:417-347-7009
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-05-15
Last Update Date:2019-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2019015946363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily