Provider Demographics
NPI:1649742602
Name:SIMON, SAMANTHA LEAH (MA-C)
Entity Type:Individual
Prefix:MRS
First Name:SAMANTHA
Middle Name:LEAH
Last Name:SIMON
Suffix:
Gender:F
Credentials:MA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:401 S 25TH ST
Mailing Address - Street 2:
Mailing Address - City:MOUNT VERNON
Mailing Address - State:WA
Mailing Address - Zip Code:98274-4772
Mailing Address - Country:US
Mailing Address - Phone:360-399-3611
Mailing Address - Fax:
Practice Address - Street 1:401 S 25TH ST
Practice Address - Street 2:
Practice Address - City:MOUNT VERNON
Practice Address - State:WA
Practice Address - Zip Code:98274-4772
Practice Address - Country:US
Practice Address - Phone:360-399-3611
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-12-31
Last Update Date:2018-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA911180810261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center