Provider Demographics
NPI:1720648561
Name:BEAUDOIN, SAMANTHA (NP)
Entity Type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:
Last Name:BEAUDOIN
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:42 BRIERE DR
Mailing Address - Street 2:
Mailing Address - City:CHICOPEE
Mailing Address - State:MA
Mailing Address - Zip Code:01020-1138
Mailing Address - Country:US
Mailing Address - Phone:413-530-1254
Mailing Address - Fax:
Practice Address - Street 1:250 N MAIN ST STE 101
Practice Address - Street 2:
Practice Address - City:EAST LONGMEADOW
Practice Address - State:MA
Practice Address - Zip Code:01028-1834
Practice Address - Country:US
Practice Address - Phone:413-525-1870
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-14
Last Update Date:2019-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MARN2309104363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily