Healthcare Provider Details

I. General information

NPI: 1255930756
Provider Name (Legal Business Name): SAMANTHA CHESTNUT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/26/2020
Last Update Date: 10/26/2020
Certification Date: 10/26/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10301 THRIFT DR APT 103
LOUISVILLE KY
40223-0096
US

IV. Provider business mailing address

10301 THRIFT DR APT 103
LOUISVILLE KY
40223-0096
US

V. Phone/Fax

Practice location:
  • Phone: 317-697-8466
  • Fax:
Mailing address:
  • Phone: 317-697-8466
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WE0003X
TaxonomyEmergency Registered Nurse
License Number1151514
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: