Healthcare Provider Details

I. General information

NPI: 1457260358
Provider Name (Legal Business Name): SAMANTHA LEE WOOD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/04/2026
Last Update Date: 09/04/2026
Certification Date: 09/04/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1414 MARYLAND AVE E
SAINT PAUL MN
55106-2824
US

IV. Provider business mailing address

1414 MARYLAND AVE E
SAINT PAUL MN
55106-2824
US

V. Phone/Fax

Practice location:
  • Phone: 651-772-3461
  • Fax: 651-772-2605
Mailing address:
  • Phone: 651-772-3461
  • Fax: 651-772-2605

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number14732
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: