Healthcare Provider Details

I. General information

NPI: 1083413785
Provider Name (Legal Business Name): SAMANTHA ANNE EADS RN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/13/2025
Last Update Date: 03/13/2025
Certification Date: 03/13/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

600 N EAGLESON AVE
BLOOMINGTON IN
47405-3190
US

IV. Provider business mailing address

600 N EAGLESON AVE
BLOOMINGTON IN
47405-3190
US

V. Phone/Fax

Practice location:
  • Phone: 812-855-7514
  • Fax: 812-856-8729
Mailing address:
  • Phone: 812-855-7514
  • Fax: 812-856-8729

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WC1400X
TaxonomyCollege Health Registered Nurse
License Number28244923A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: