Healthcare Provider Details

I. General information

NPI: 1598526444
Provider Name (Legal Business Name): SAMANTHA DANIELLE PUTNAM
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: SAMANTHA DANIELLE GARZA

II. Dates (important events)

Enumeration Date: 01/18/2024
Last Update Date: 01/09/2025
Certification Date: 01/09/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

825 FAIRFAX AVE
NORFOLK VA
23507-1912
US

IV. Provider business mailing address

825 FAIRFAX AVE
NORFOLK VA
23507-1914
US

V. Phone/Fax

Practice location:
  • Phone: 757-446-5600
  • Fax:
Mailing address:
  • Phone: 757-446-5600
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080S0012X
TaxonomyPediatric Sleep Medicine Physician
License Number0110010307
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: