Healthcare Provider Details

I. General information

NPI: 1154824498
Provider Name (Legal Business Name): SAMANTHA E AMOS NP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: SAMANTHA E PARKS RN

II. Dates (important events)

Enumeration Date: 03/13/2018
Last Update Date: 05/09/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

210 QUAIL RUN RD
SUGAR GROVE VA
24375-3286
US

IV. Provider business mailing address

PO BOX 249
YADKINVILLE NC
27055-0249
US

V. Phone/Fax

Practice location:
  • Phone: 276-686-5334
  • Fax:
Mailing address:
  • Phone: 336-679-4963
  • Fax: 336-679-2549

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number5010487
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License Number0024175952
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: