Provider Demographics
NPI:1740889328
Name:WILL, SAMANTHA KATHLEEN ESTELLE
Entity type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:KATHLEEN ESTELLE
Last Name:WILL
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 1:19964 MERIDIAN RD
Mailing Address - Street 2:
Mailing Address - City:GROSSE ILE
Mailing Address - State:MI
Mailing Address - Zip Code:48138-1075
Mailing Address - Country:US
Mailing Address - Phone:734-818-9576
Mailing Address - Fax:
Practice Address - Street 1:1537 MONROE ST
Practice Address - Street 2:
Practice Address - City:DEARBORN
Practice Address - State:MI
Practice Address - Zip Code:48124-2842
Practice Address - Country:US
Practice Address - Phone:313-359-2100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-10-23
Last Update Date:2020-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704313954363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health