MEDICARE: SAMANTHA ANN CAPISTRANT PMHNP-BC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LP0808X	Psychiatric/Mental Health Nurse Practitioner	RN2302151	MA
2	163WP0808X	Psychiatric/Mental Health Registered Nurse	RN2302151	MA
3	363LP0808X	Psychiatric/Mental Health Nurse Practitioner	4053788	KY

General Provider Information

NPI Number	:	1962130302
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SAMANTHA ANN CAPISTRANT PMHNP-BC

Provider Business Mailing Address
First Line	:	PO BOX 802
Second Line	:
City	:	BEREA
State	:	KY
Zip	:	40403-0802
Country	:	US
Telephone Number	:	859-428-7862
Fax Number	:	859-999-7869

Provider Business Practice Location Address
First Line	:	208 KIDD DR
Second Line	:
City	:	BEREA
State	:	KY
Zip	:	40403-9593
Country	:	US
Telephone Number	:	859-428-7862
Fax Number	:	859-999-7869

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/12/2022
Last Update Date	:	06/01/2026

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