Provider Demographics
NPI:1245706548
Name:NOETH, SAMANTHA KAY (MMSN)
Entity type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:KAY
Last Name:NOETH
Suffix:
Gender:
Credentials:MMSN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:715 BROADWAY ST
Mailing Address - Street 2:
Mailing Address - City:GILLESPIE
Mailing Address - State:IL
Mailing Address - Zip Code:62033-1166
Mailing Address - Country:US
Mailing Address - Phone:217-839-4491
Mailing Address - Fax:217-839-5030
Practice Address - Street 1:12 N 64TH ST
Practice Address - Street 2:
Practice Address - City:BELLEVILLE
Practice Address - State:IL
Practice Address - Zip Code:62223-3809
Practice Address - Country:US
Practice Address - Phone:618-877-4420
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-15
Last Update Date:2025-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209018361363L00000X
IL209.018361363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner