Healthcare Provider Details

I. General information

NPI: 1720626112
Provider Name (Legal Business Name): SAMANTHA FRIAS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/16/2019
Last Update Date: 12/16/2019
Certification Date: 12/16/2019
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1260 N DUTTON AVE
SANTA ROSA CA
95401-4659
US

IV. Provider business mailing address

1260 N DUTTON AVE
SANTA ROSA CA
95401-4659
US

V. Phone/Fax

Practice location:
  • Phone: 707-568-2300
  • Fax: 707-568-2304
Mailing address:
  • Phone: 707-568-2300
  • Fax: 707-568-2304

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code174H00000X
TaxonomyHealth Educator
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: