Provider Demographics
NPI:1851843759
Name:WOOD, SAMANTHA JO
Entity Type:Individual
Prefix:MS
First Name:SAMANTHA
Middle Name:JO
Last Name:WOOD
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16495 GRATIOT RD
Mailing Address - Street 2:
Mailing Address - City:HEMLOCK
Mailing Address - State:MI
Mailing Address - Zip Code:48626-9377
Mailing Address - Country:US
Mailing Address - Phone:989-525-6233
Mailing Address - Fax:
Practice Address - Street 1:16495 GRATIOT RD
Practice Address - Street 2:
Practice Address - City:HEMLOCK
Practice Address - State:MI
Practice Address - Zip Code:48626-9377
Practice Address - Country:US
Practice Address - Phone:989-525-6233
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-10-27
Last Update Date:2016-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program