Healthcare Provider Details

I. General information

NPI: 1255584348
Provider Name (Legal Business Name): SAMANTHA WHITE APN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/03/2008
Last Update Date: 03/08/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1276 N CLYBOURN AVE
CHICAGO IL
60610-2089
US

IV. Provider business mailing address

5140 S HYDE PARK BLVD APT 20F
CHICAGO IL
60615-4267
US

V. Phone/Fax

Practice location:
  • Phone: 312-337-1073
  • Fax: 312-337-7460
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code364SG0600X
TaxonomyGerontology Clinical Nurse Specialist
License Number209017043
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number041.372117
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: