Provider Demographics
NPI:1972035061
Name:EITING, SAMANTHA A (APNP)
Entity Type:Individual
Prefix:MRS
First Name:SAMANTHA
Middle Name:A
Last Name:EITING
Suffix:
Gender:F
Credentials:APNP
Other - Prefix:MISS
Other - First Name:SAMANTHA
Other - Middle Name:A
Other - Last Name:KANTELBERG
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 8003
Mailing Address - Street 2:
Mailing Address - City:APPLETON
Mailing Address - State:WI
Mailing Address - Zip Code:54912-8003
Mailing Address - Country:US
Mailing Address - Phone:920-830-5900
Mailing Address - Fax:920-738-5787
Practice Address - Street 1:W3208 VAN ROY RD
Practice Address - Street 2:
Practice Address - City:APPLETON
Practice Address - State:WI
Practice Address - Zip Code:54915-4086
Practice Address - Country:US
Practice Address - Phone:866-455-8111
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-03-29
Last Update Date:2017-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI178207363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner