Healthcare Provider Details

I. General information

NPI: 1689398521
Provider Name (Legal Business Name): SAMANTHA R MYER APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: SAMANTHA R KAUCHAK APRN

II. Dates (important events)

Enumeration Date: 10/03/2022
Last Update Date: 10/05/2026
Certification Date: 10/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5875 E RIVERSIDE BLVD
ROCKFORD IL
61114-4937
US

IV. Provider business mailing address

PO BOX 735263
CHICAGO IL
60673-5263
US

V. Phone/Fax

Practice location:
  • Phone: 815-398-9491
  • Fax: 815-381-7498
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number209026147
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number041428462
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: