Provider Demographics
NPI:1356139570
Name:SMITH, SAMANTHA JEAN (RN, IBCLC)
Entity type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:JEAN
Last Name:SMITH
Suffix:
Gender:
Credentials:RN, IBCLC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2300 N EDWARD ST
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:IL
Mailing Address - Zip Code:62526-4192
Mailing Address - Country:US
Mailing Address - Phone:217-876-3400
Mailing Address - Fax:217-876-3408
Practice Address - Street 1:2300 N EDWARD ST
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:IL
Practice Address - Zip Code:62526-4192
Practice Address - Country:US
Practice Address - Phone:217-876-3400
Practice Address - Fax:217-876-3408
Is Sole Proprietor?:No
Enumeration Date:2025-04-28
Last Update Date:2025-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ILL-87813163WL0100X
IL041320969163WL0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WL0100XNursing Service ProvidersRegistered NurseLactation Consultant