Provider Demographics
NPI:1982216032
Name:DELAWDER, SAMANTHA NICOLE
Entity Type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:NICOLE
Last Name:DELAWDER
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 1:72 HARVEY SITES DR
Mailing Address - Street 2:
Mailing Address - City:PETERSBURG
Mailing Address - State:WV
Mailing Address - Zip Code:26847-8605
Mailing Address - Country:US
Mailing Address - Phone:304-257-8593
Mailing Address - Fax:
Practice Address - Street 1:72 HARVEY SITES DR
Practice Address - Street 2:
Practice Address - City:PETERSBURG
Practice Address - State:WV
Practice Address - Zip Code:26847-8605
Practice Address - Country:US
Practice Address - Phone:304-257-8593
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-20
Last Update Date:2020-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV3747P1801XMedicaid