Provider Demographics
NPI:1700388931
Name:WALDECK, SAMANTHA (APRN, CNP)
Entity Type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:
Last Name:WALDECK
Suffix:
Gender:F
Credentials:APRN, CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:67 TRUMBULL DR
Mailing Address - Street 2:
Mailing Address - City:HUDSON
Mailing Address - State:OH
Mailing Address - Zip Code:44236-2731
Mailing Address - Country:US
Mailing Address - Phone:330-391-0390
Mailing Address - Fax:
Practice Address - Street 1:26900 CEDAR RD
Practice Address - Street 2:
Practice Address - City:BEACHWOOD
Practice Address - State:OH
Practice Address - Zip Code:44122-1191
Practice Address - Country:US
Practice Address - Phone:216-839-3904
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-03-04
Last Update Date:2018-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHAPRN.CNP.022429363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily