Healthcare Provider Details

I. General information

NPI: 1629448493
Provider Name (Legal Business Name): SAMANTHA DISANTIS APN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/05/2015
Last Update Date: 11/13/2024
Certification Date: 11/13/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

141 BRIDGETON PIKE UNIT B
MULLICA HILL NJ
08062-2615
US

IV. Provider business mailing address

PO BOX 7776
LANCASTER PA
17601
US

V. Phone/Fax

Practice location:
  • Phone: 856-291-8600
  • Fax: 856-291-8610
Mailing address:
  • Phone: 888-985-2727
  • Fax: 856-779-0211

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number26NR1252700
License Number StateNJ
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number26NJ00595500
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: