Provider Demographics
NPI:1609436922
Name:MCKINNON, SAMANTHA (APRN, NP-C)
Entity Type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:
Last Name:MCKINNON
Suffix:
Gender:F
Credentials:APRN, NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8891 CENTRAL AVE STE A
Mailing Address - Street 2:
Mailing Address - City:MONTCLAIR
Mailing Address - State:CA
Mailing Address - Zip Code:91763-1685
Mailing Address - Country:US
Mailing Address - Phone:909-297-3361
Mailing Address - Fax:
Practice Address - Street 1:5131 NELLIE CT
Practice Address - Street 2:
Practice Address - City:RANCHO CUCAMONGA
Practice Address - State:CA
Practice Address - Zip Code:91739-5132
Practice Address - Country:US
Practice Address - Phone:909-297-3361
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-18
Last Update Date:2024-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDT20230052163W00000X
CA95308835163W00000X
TX801309163W00000X
UT12707814-3102163W00000X
IA165389163W00000X
CO1686036163W00000X
NY352966363LF0000X
COC-APN.0003288-C-NP363LF0000X
MDAC003943363LF0000X
TXAP142077363LF0000X
FL11019305363LF0000X
WAAP61224221363LF0000X
UT12707814-4405363LF0000X
IAA165389363LF0000X
CA95023202363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse