Healthcare Provider Details

I. General information

NPI: 1861328296
Provider Name (Legal Business Name): SAMANTHA WILS LPN, CLS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/23/2026
Last Update Date: 06/23/2026
Certification Date: 06/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3409 LUDINGTON ST STE 204
ESCANABA MI
49829-4213
US

IV. Provider business mailing address

3409 LUDINGTON ST STE 204
ESCANABA MI
49829-4213
US

V. Phone/Fax

Practice location:
  • Phone: 906-786-1356
  • Fax: 906-789-4503
Mailing address:
  • Phone: 906-786-1356
  • Fax: 906-789-4503

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174N00000X
TaxonomyLactation Consultant (Non-RN)
License Number4703107035
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: