Healthcare Provider Details

I. General information

NPI: 1174381529
Provider Name (Legal Business Name): SAMANTHA WOMACK FNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: SAMANTHA STASICA

II. Dates (important events)

Enumeration Date: 03/11/2024
Last Update Date: 03/11/2024
Certification Date: 03/11/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1131 LEIGHTON AVE
ANNISTON AL
36207-4610
US

IV. Provider business mailing address

1131 LEIGHTON AVE
ANNISTON AL
36207-4610
US

V. Phone/Fax

Practice location:
  • Phone: 256-237-0025
  • Fax: 256-237-4795
Mailing address:
  • Phone: 256-237-0025
  • Fax: 256-237-4795

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number1-139213
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: