Provider Demographics
NPI:1821660945
Name:MIFFIN, SAMANTHA RENEE (CNA PBT)
Entity Type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:RENEE
Last Name:MIFFIN
Suffix:
Gender:F
Credentials:CNA PBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6037 HARE RD
Mailing Address - Street 2:
Mailing Address - City:HENRICO
Mailing Address - State:VA
Mailing Address - Zip Code:23231-7921
Mailing Address - Country:US
Mailing Address - Phone:804-939-0092
Mailing Address - Fax:
Practice Address - Street 1:6037 HARE RD
Practice Address - Street 2:
Practice Address - City:HENRICO
Practice Address - State:VA
Practice Address - Zip Code:23231-7921
Practice Address - Country:US
Practice Address - Phone:804-939-0092
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-16
Last Update Date:2022-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA1401135672247200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes247200000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, OtherGroup - Single Specialty