Provider Demographics
NPI:1417526864
Name:WHITEHEAD, SAMANTHA (FNP-BC)
Entity Type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:
Last Name:WHITEHEAD
Suffix:
Gender:F
Credentials:FNP-BC
Other - Prefix:
Other - First Name:SAMANTHA
Other - Middle Name:
Other - Last Name:CRISMON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:102 N 410 E
Mailing Address - Street 2:
Mailing Address - City:VINEYARD
Mailing Address - State:UT
Mailing Address - Zip Code:84059-7585
Mailing Address - Country:US
Mailing Address - Phone:734-353-2653
Mailing Address - Fax:
Practice Address - Street 1:765 E MARKET PLACE DR
Practice Address - Street 2:
Practice Address - City:SPANISH FORK
Practice Address - State:UT
Practice Address - Zip Code:84660-1396
Practice Address - Country:US
Practice Address - Phone:734-353-2653
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-21
Last Update Date:2022-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT5942923-3102163W00000X
UT5942923-4405363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care
No163W00000XNursing Service ProvidersRegistered Nurse