Healthcare Provider Details

I. General information

NPI: 1902583917
Provider Name (Legal Business Name): ASHLEY SAMANIEGO PMHNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: ASHLEY MITCHAM RN

II. Dates (important events)

Enumeration Date: 06/30/2023
Last Update Date: 11/04/2024
Certification Date: 11/04/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2204 PAVILION DR STE 107
KINGSPORT TN
37660-4651
US

IV. Provider business mailing address

1021 W OAKLAND AVE STE 310
JOHNSON CITY TN
37604-2192
US

V. Phone/Fax

Practice location:
  • Phone: 423-392-6100
  • Fax:
Mailing address:
  • Phone: 423-952-2111
  • Fax: 423-282-1657

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WP0808X
TaxonomyPsychiatric/Mental Health Registered Nurse
License Number180297
License Number StateTN
# 2
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number36562
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: