Provider Demographics
NPI:1932734092
Name:WELCH, SAMANTHA DANIELLE (FNP)
Entity Type:Individual
Prefix:MRS
First Name:SAMANTHA
Middle Name:DANIELLE
Last Name:WELCH
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:94 COUNTY ROAD 4230
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:MO
Mailing Address - Zip Code:65560-8129
Mailing Address - Country:US
Mailing Address - Phone:573-247-8980
Mailing Address - Fax:
Practice Address - Street 1:500 MAIN ST
Practice Address - Street 2:
Practice Address - City:CABOOL
Practice Address - State:MO
Practice Address - Zip Code:65689-8104
Practice Address - Country:US
Practice Address - Phone:417-962-3015
Practice Address - Fax:417-962-5240
Is Sole Proprietor?:No
Enumeration Date:2020-03-10
Last Update Date:2020-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2020008394363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO26D2006074OtherCLIA MG
MO26D0859759OtherCLIA CMC
MO26D0679044OtherCLIA LFC
MO26D2178130OtherCLIA FHC
MO420081939Medicaid