Healthcare Provider Details

I. General information

NPI: 1568291672
Provider Name (Legal Business Name): SAMANTHA DANIELLE STATHAM NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: SAMANTHA DANIELLE BROWDER RN

II. Dates (important events)

Enumeration Date: 07/29/2024
Last Update Date: 09/09/2025
Certification Date: 09/09/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

129 CENTER ST STE B
RICHLAND MS
39218-4800
US

IV. Provider business mailing address

129 CENTER ST STE B
RICHLAND MS
39218-4800
US

V. Phone/Fax

Practice location:
  • Phone: 769-233-7141
  • Fax:
Mailing address:
  • Phone: 769-233-7141
  • Fax: 769-233-7726

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number37098
License Number StateTN
# 2
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number906894
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: