Healthcare Provider Details

I. General information

NPI: 1952052243
Provider Name (Legal Business Name): SAMANTHA M WIDEMAN APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/18/2022
Last Update Date: 12/29/2022
Certification Date: 12/29/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

133 HARMONY PARK CIR
HOT SPRINGS AR
71913-5417
US

IV. Provider business mailing address

PO BOX 749495
ATLANTA GA
30374-9495
US

V. Phone/Fax

Practice location:
  • Phone: 501-624-7700
  • Fax:
Mailing address:
  • Phone: 239-432-8331
  • Fax: 813-321-1296

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number216236
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: