Provider Demographics
NPI:1679128730
Name:BANEY, SAMANTHA ANN (APRN)
Entity Type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:ANN
Last Name:BANEY
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15355 E DEES DR
Mailing Address - Street 2:
Mailing Address - City:MONROE CENTER
Mailing Address - State:IL
Mailing Address - Zip Code:61052-9747
Mailing Address - Country:US
Mailing Address - Phone:815-543-0545
Mailing Address - Fax:
Practice Address - Street 1:2313 N ROCKTON AVE
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61103-3618
Practice Address - Country:US
Practice Address - Phone:815-964-2200
Practice Address - Fax:815-965-7722
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-06
Last Update Date:2019-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209.019754363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily