Provider Demographics
NPI:1245848928
Name:KISAMORE, SAMANTHA DANIELLE
Entity type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:DANIELLE
Last Name:KISAMORE
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 1:12 MAPLE HILL AVE STE 1
Mailing Address - Street 2:
Mailing Address - City:PETERSBURG
Mailing Address - State:WV
Mailing Address - Zip Code:26847-1547
Mailing Address - Country:US
Mailing Address - Phone:304-257-9298
Mailing Address - Fax:
Practice Address - Street 1:12 MAPLE HILL AVE STE 1
Practice Address - Street 2:
Practice Address - City:PETERSBURG
Practice Address - State:WV
Practice Address - Zip Code:26847-1547
Practice Address - Country:US
Practice Address - Phone:304-257-9298
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-07-17
Last Update Date:2020-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV80681376K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376K00000XNursing Service Related ProvidersNurse's Aide