Healthcare Provider Details

I. General information

NPI: 1962130302
Provider Name (Legal Business Name): SAMANTHA ANN CAPISTRANT PMHNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/12/2022
Last Update Date: 06/01/2026
Certification Date: 06/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

208 KIDD DR
BEREA KY
40403-9593
US

IV. Provider business mailing address

PO BOX 802
BEREA KY
40403-0802
US

V. Phone/Fax

Practice location:
  • Phone: 859-428-7862
  • Fax: 859-999-7869
Mailing address:
  • Phone: 859-428-7862
  • Fax: 859-999-7869

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberRN2302151
License Number StateMA
# 2
Primary TaxonomyN
Taxonomy Code163WP0808X
TaxonomyPsychiatric/Mental Health Registered Nurse
License NumberRN2302151
License Number StateMA
# 3
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number4053788
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: