Healthcare Provider Details

I. General information

NPI: 1396190088
Provider Name (Legal Business Name): SAMANTHA OLMOS APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/29/2016
Last Update Date: 08/15/2022
Certification Date: 08/15/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1901 VETERANS MEMORIAL DR
TEMPLE TX
76504-7451
US

IV. Provider business mailing address

9023 LONESOME OAK DR
TEMPLE TX
76502-3165
US

V. Phone/Fax

Practice location:
  • Phone: 254-778-4811
  • Fax:
Mailing address:
  • Phone: 254-913-4665
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number876459
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number1087847
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: