Provider Demographics
NPI:1487529277
Name:SMITH, SAMANTHA WALTERS
Entity type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:WALTERS
Last Name:SMITH
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 1:2510 BERT KOUNS INDUSTRIAL LOOP STE 215
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71118-3119
Mailing Address - Country:US
Mailing Address - Phone:318-212-5970
Mailing Address - Fax:318-212-5975
Practice Address - Street 1:2510 BERT KOUNS INDUSTRIAL LOOP STE 215
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71118-3119
Practice Address - Country:US
Practice Address - Phone:318-212-5970
Practice Address - Fax:318-212-5975
Is Sole Proprietor?:Yes
Enumeration Date:2025-10-09
Last Update Date:2025-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA00000363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care