Healthcare Provider Details

I. General information

NPI: 1396394706
Provider Name (Legal Business Name): SAMANTHA HUMPHREY
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/09/2019
Last Update Date: 10/04/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

328 E HINES HILL RD
BOSTON HEIGHTS OH
44236-1118
US

IV. Provider business mailing address

328 E HINES HILL RD
BOSTON HEIGHTS OH
44236-1118
US

V. Phone/Fax

Practice location:
  • Phone: 330-342-5437
  • Fax: 330-342-9006
Mailing address:
  • Phone: 330-342-5437
  • Fax: 330-342-9006

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License NumberAPRN.CNP.025569
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: