Provider Demographics
NPI:1780074401
Name:SAMANTHA CRICKMORE
Entity type:Organization
Organization Name:SAMANTHA CRICKMORE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LICENSED MIDWIFE
Authorized Official - Prefix:MRS
Authorized Official - First Name:SAMANTHA
Authorized Official - Middle Name:BROOKE
Authorized Official - Last Name:CRICKMORE
Authorized Official - Suffix:
Authorized Official - Credentials:LM, CPM
Authorized Official - Phone:352-278-4746
Mailing Address - Street 1:721 FOXBRIAR CV
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32221-1508
Mailing Address - Country:US
Mailing Address - Phone:352-278-4746
Mailing Address - Fax:
Practice Address - Street 1:721 FOXBRIAR CV
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32221-1508
Practice Address - Country:US
Practice Address - Phone:352-278-4746
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-02-02
Last Update Date:2015-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMW306261QB0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QB0400XAmbulatory Health Care FacilitiesClinic/CenterBirthing