Provider Demographics
NPI:1831717008
Name:SMITH, SAMANTHA
Entity type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:
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 1:4428 DR THOMAS WALKER RD
Mailing Address - Street 2:
Mailing Address - City:ROSE HILL
Mailing Address - State:VA
Mailing Address - Zip Code:24281-8382
Mailing Address - Country:US
Mailing Address - Phone:276-244-2157
Mailing Address - Fax:
Practice Address - Street 1:4428 DR THOMAS WALKER RD
Practice Address - Street 2:
Practice Address - City:ROSE HILL
Practice Address - State:VA
Practice Address - Zip Code:24281-8382
Practice Address - Country:US
Practice Address - Phone:276-244-2157
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-13
Last Update Date:2022-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024180780363LF0000X
TN29078363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA0001259809OtherREGISTERED NURSING LICENSURE