Provider Demographics
NPI:1982867131
Name:ERICKSON, SAMANTHA RAE
Entity Type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:RAE
Last Name:ERICKSON
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 1:38197 175TH AVE
Mailing Address - Street 2:
Mailing Address - City:PELICAN RAPIDS
Mailing Address - State:MN
Mailing Address - Zip Code:56572
Mailing Address - Country:US
Mailing Address - Phone:218-731-0187
Mailing Address - Fax:
Practice Address - Street 1:106 4TH AVE NORTH
Practice Address - Street 2:
Practice Address - City:FERGUS FALLS
Practice Address - State:MN
Practice Address - Zip Code:56537-1034
Practice Address - Country:US
Practice Address - Phone:218-998-3778
Practice Address - Fax:218-998-3187
Is Sole Proprietor?:No
Enumeration Date:2008-07-08
Last Update Date:2008-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN0662752164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse