Provider Demographics
NPI:1629717384
Name:BLANC, SAMANTHA NICOLE (FNP)
Entity Type:Individual
Prefix:MRS
First Name:SAMANTHA
Middle Name:NICOLE
Last Name:BLANC
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:207 N CHASE ST
Mailing Address - Street 2:
Mailing Address - City:JOHNSTOWN
Mailing Address - State:NY
Mailing Address - Zip Code:12095-1810
Mailing Address - Country:US
Mailing Address - Phone:518-332-6466
Mailing Address - Fax:
Practice Address - Street 1:5344 SACANDAGA RD
Practice Address - Street 2:
Practice Address - City:GALWAY
Practice Address - State:NY
Practice Address - Zip Code:12074-2422
Practice Address - Country:US
Practice Address - Phone:518-882-6955
Practice Address - Fax:518-886-5880
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-01
Last Update Date:2022-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF349703363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily