Healthcare Provider Details

I. General information

NPI: 1043784937
Provider Name (Legal Business Name): SAMANTHA AMEPEROSA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/14/2019
Last Update Date: 01/14/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10701 MAIN ST
FAIRFAX VA
22030-6904
US

IV. Provider business mailing address

13187 ADAMS ST
QUANTICO VA
22134-4201
US

V. Phone/Fax

Practice location:
  • Phone: 703-273-7705
  • Fax:
Mailing address:
  • Phone: 808-393-0570
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: