Provider Demographics
NPI:1710254016
Name:KINNINGER, SAMANTHA PERRY (CRNA)
Entity Type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:PERRY
Last Name:KINNINGER
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:SAMANTHA
Other - Middle Name:J
Other - Last Name:PERRY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CRNA
Mailing Address - Street 1:9263 MEDICAL PLAZA DR
Mailing Address - Street 2:STE E
Mailing Address - City:CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29406-7112
Mailing Address - Country:US
Mailing Address - Phone:843-572-1228
Mailing Address - Fax:877-561-7564
Practice Address - Street 1:9263 MEDICAL PLAZA DR
Practice Address - Street 2:STE E
Practice Address - City:CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29406-7112
Practice Address - Country:US
Practice Address - Phone:843-572-1228
Practice Address - Fax:877-561-7564
Is Sole Proprietor?:No
Enumeration Date:2011-11-30
Last Update Date:2013-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC105582390200000X
SC17687367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCAN2190Medicaid
SCAN2190Medicaid