Healthcare Provider Details

I. General information

NPI: 1245707645
Provider Name (Legal Business Name): SAMANTHA RAE CLEMENS LVN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/24/2018
Last Update Date: 10/24/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1133 COLOMA WAY STE C
ROSEVILLE CA
95661-4480
US

IV. Provider business mailing address

1133 COLOMA WAY STE C
ROSEVILLE CA
95661-4480
US

V. Phone/Fax

Practice location:
  • Phone: 916-774-6647
  • Fax: 916-774-6456
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164X00000X
TaxonomyLicensed Vocational Nurse
License Number688371
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: