Healthcare Provider Details

I. General information

NPI: 1942648977
Provider Name (Legal Business Name): SAMANTHA J BOOTH AU.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/12/2013
Last Update Date: 06/12/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

333 WALLER AVE STE 300
LEXINGTON KY
40504-2927
US

IV. Provider business mailing address

333 WALLER AVE STE 300
LEXINGTON KY
40504-2927
US

V. Phone/Fax

Practice location:
  • Phone: 859-252-3170
  • Fax: 859-225-7155
Mailing address:
  • Phone: 859-252-3170
  • Fax: 859-225-7155

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code231H00000X
TaxonomyAudiologist
License Number0571
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: