Healthcare Provider Details

I. General information

NPI: 1639711799
Provider Name (Legal Business Name): SAMANTHA JEAN MEDLEY FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

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

III. Provider practice location address

5826 ESPLANADE DR STE 102
CORPUS CHRISTI TX
78414-4198
US

IV. Provider business mailing address

PO BOX 61160
CORPUS CHRISTI TX
78466-1160
US

V. Phone/Fax

Practice location:
  • Phone: 361-500-2898
  • Fax: 361-334-0794
Mailing address:
  • Phone: 361-500-2898
  • Fax: 361-857-0572

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAP143420
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: