Provider Demographics
NPI:1457745358
Name:CHRISTOPHER, SAMANTHA JO (APN)
Entity type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:JO
Last Name:CHRISTOPHER
Suffix:
Gender:F
Credentials:APN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:209 W COMMERCIAL DR STE E
Mailing Address - Street 2:
Mailing Address - City:CARTERVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62918-2057
Mailing Address - Country:US
Mailing Address - Phone:618-684-7087
Mailing Address - Fax:618-822-4045
Practice Address - Street 1:702 CHESTNUT ST
Practice Address - Street 2:
Practice Address - City:MURPHYSBORO
Practice Address - State:IL
Practice Address - Zip Code:62966-2650
Practice Address - Country:US
Practice Address - Phone:618-684-7087
Practice Address - Fax:618-822-4045
Is Sole Proprietor?:No
Enumeration Date:2015-03-28
Last Update Date:2024-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL277002107363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL370966854002Medicaid