Healthcare Provider Details

I. General information

NPI: 1205401270
Provider Name (Legal Business Name): SAMANTHA ELAINE WIESNER APRN, FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/23/2021
Last Update Date: 05/31/2023
Certification Date: 05/31/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6139 GLENWAY AVE
CINCINNATI OH
45211-6312
US

IV. Provider business mailing address

6139 GLENWAY AVE
CINCINNATI OH
45211-6312
US

V. Phone/Fax

Practice location:
  • Phone: 513-346-3399
  • Fax: 513-389-0957
Mailing address:
  • Phone: 513-346-3399
  • Fax: 513-389-0957

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number3015961
License Number StateKY
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAPRN.CNP.0028979
License Number StateOH
# 3
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number0028979
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: