Provider Demographics
NPI:1457750234
Name:INGERICK, SAMANTHA BURNHAM (NP)
Entity Type:Individual
Prefix:MRS
First Name:SAMANTHA
Middle Name:BURNHAM
Last Name:INGERICK
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:SMANTHA
Other - Middle Name:
Other - Last Name:BURNHAM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 255
Mailing Address - Street 2:
Mailing Address - City:MANCHESTER
Mailing Address - State:VT
Mailing Address - Zip Code:05254-0255
Mailing Address - Country:US
Mailing Address - Phone:802-768-9136
Mailing Address - Fax:802-662-2173
Practice Address - Street 1:4384 MAIN STREET
Practice Address - Street 2:
Practice Address - City:MANCHESTER
Practice Address - State:VT
Practice Address - Zip Code:05254-9207
Practice Address - Country:US
Practice Address - Phone:802-768-9136
Practice Address - Fax:802-662-2173
Is Sole Proprietor?:Yes
Enumeration Date:2014-08-18
Last Update Date:2023-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF382385-1363LP0200X
NH088196-23363LP0200X
VT101.0134299363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics