Provider Demographics
NPI:1770707523
Name:BROWN, SAMANTHA JO (FNP)
Entity type:Individual
Prefix:MRS
First Name:SAMANTHA
Middle Name:JO
Last Name:BROWN
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:26136 US HIGHWAY 59
Mailing Address - Street 2:
Mailing Address - City:FAIRFAX
Mailing Address - State:MO
Mailing Address - Zip Code:64446-9635
Mailing Address - Country:US
Mailing Address - Phone:660-686-2211
Mailing Address - Fax:
Practice Address - Street 1:26136 US HIGHWAY 59
Practice Address - Street 2:
Practice Address - City:FAIRFAX
Practice Address - State:MO
Practice Address - Zip Code:64446-8155
Practice Address - Country:US
Practice Address - Phone:660-686-2211
Practice Address - Fax:660-686-2618
Is Sole Proprietor?:No
Enumeration Date:2007-04-12
Last Update Date:2019-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IAA111977363LF0000X
MO2004002504363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOBCBSOther00594011