Provider Demographics
NPI:1508208042
Name:REICKS, SAMANTHA JO MIKOTA (DNP, ARNP)
Entity Type:Individual
Prefix:DR
First Name:SAMANTHA
Middle Name:JO MIKOTA
Last Name:REICKS
Suffix:
Gender:F
Credentials:DNP, ARNP
Other - Prefix:
Other - First Name:SAMANTHA
Other - Middle Name:JO
Other - Last Name:MIKOTA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:901 MONTGOMERY ST
Mailing Address - Street 2:
Mailing Address - City:DECORAH
Mailing Address - State:IA
Mailing Address - Zip Code:52101-2325
Mailing Address - Country:US
Mailing Address - Phone:563-382-2911
Mailing Address - Fax:563-387-3102
Practice Address - Street 1:901 MONTGOMERY ST
Practice Address - Street 2:
Practice Address - City:DECORAH
Practice Address - State:IA
Practice Address - Zip Code:52101-2325
Practice Address - Country:US
Practice Address - Phone:563-382-2911
Practice Address - Fax:563-387-3102
Is Sole Proprietor?:No
Enumeration Date:2013-07-25
Last Update Date:2017-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IAA121332363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA1508208042Medicaid