Provider Demographics
NPI:1013267152
Name:JUSTICE, SAMANTHA JOANNE (NP)
Entity Type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:JOANNE
Last Name:JUSTICE
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 92
Mailing Address - Street 2:
Mailing Address - City:ASHLAND
Mailing Address - State:MS
Mailing Address - Zip Code:38603-0092
Mailing Address - Country:US
Mailing Address - Phone:662-224-8951
Mailing Address - Fax:662-224-6801
Practice Address - Street 1:1310 MAIN STREET
Practice Address - Street 2:
Practice Address - City:TISHOMINGO
Practice Address - State:MS
Practice Address - Zip Code:38873-3887
Practice Address - Country:US
Practice Address - Phone:662-471-9416
Practice Address - Fax:662-438-7760
Is Sole Proprietor?:No
Enumeration Date:2012-09-17
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR874488363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MJ2824868OtherDEA
MJ2824868OtherDEA