Healthcare Provider Details

I. General information

NPI: 1043611627
Provider Name (Legal Business Name): SAMANTHA NADEAU
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/15/2014
Last Update Date: 09/15/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 ANNA MARSH LANE
BRATTLEBORO VT
05301
US

IV. Provider business mailing address

PO BOX 803 ANNA MARSH LANE
BRATTLEBORO VT
05301
US

V. Phone/Fax

Practice location:
  • Phone: 802-257-7787
  • Fax:
Mailing address:
  • Phone: 802-257-7787
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number055.0031223
License Number StateVT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: