Provider Demographics
NPI:1609359322
Name:VAIL, SAMANTHA JO
Entity Type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:JO
Last Name:VAIL
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 1:38 MAPLE PL
Mailing Address - Street 2:
Mailing Address - City:ILION
Mailing Address - State:NY
Mailing Address - Zip Code:13357-2258
Mailing Address - Country:US
Mailing Address - Phone:315-717-5522
Mailing Address - Fax:
Practice Address - Street 1:325 5TH AVE
Practice Address - Street 2:
Practice Address - City:FRANKFORT
Practice Address - State:NY
Practice Address - Zip Code:13340-3622
Practice Address - Country:US
Practice Address - Phone:315-717-7442
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-09-09
Last Update Date:2018-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist