Provider Demographics
NPI:1568808954
Name:PATE, SAMANTHA SUE
Entity Type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:SUE
Last Name:PATE
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 1:18703 COUNTY ROAD C
Mailing Address - Street 2:
Mailing Address - City:VALDERS
Mailing Address - State:WI
Mailing Address - Zip Code:54245-9401
Mailing Address - Country:US
Mailing Address - Phone:920-242-7526
Mailing Address - Fax:
Practice Address - Street 1:18703 COUNTY ROAD C
Practice Address - Street 2:
Practice Address - City:VALDERS
Practice Address - State:WI
Practice Address - Zip Code:54245-9401
Practice Address - Country:US
Practice Address - Phone:920-242-7526
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-05-13
Last Update Date:2013-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI311267-31164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse