Healthcare Provider Details

I. General information

NPI: 1285333799
Provider Name (Legal Business Name): SAMANTHA JO HERBERT APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/23/2023
Last Update Date: 09/11/2023
Certification Date: 09/11/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

836 W WELLINGTON AVE
CHICAGO IL
60657-5147
US

IV. Provider business mailing address

4525 N KEYSTONE AVE
CHICAGO IL
60630-4411
US

V. Phone/Fax

Practice location:
  • Phone: 773-296-5634
  • Fax:
Mailing address:
  • Phone: 517-455-6449
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code364SA2100X
TaxonomyAcute Care Clinical Nurse Specialist
License Number209.027256
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: