Healthcare Provider Details

I. General information

NPI: 1003708769
Provider Name (Legal Business Name): SAMARAH LYNN NINIS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/17/2025
Last Update Date: 12/18/2025
Certification Date: 12/18/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7417 KINGSTON PIKE
KNOXVILLE TN
37919-5606
US

IV. Provider business mailing address

7417 KINGSTON PIKE
KNOXVILLE TN
37919-5606
US

V. Phone/Fax

Practice location:
  • Phone: 703-861-9862
  • Fax:
Mailing address:
  • Phone: 703-861-9862
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number7889
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: