Provider Demographics
NPI:1942089768
Name:MUNRO, SAMANTHA L
Entity Type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:L
Last Name:MUNRO
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 1:726 SUNSET BLVD
Mailing Address - Street 2:
Mailing Address - City:OFALLON
Mailing Address - State:IL
Mailing Address - Zip Code:62269
Mailing Address - Country:US
Mailing Address - Phone:618-726-2229
Mailing Address - Fax:
Practice Address - Street 1:2236 VADALABENE DR
Practice Address - Street 2:
Practice Address - City:MARYVILLE
Practice Address - State:IL
Practice Address - Zip Code:62062-5844
Practice Address - Country:US
Practice Address - Phone:618-726-2229
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-09-22
Last Update Date:2023-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209028045363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily