Healthcare Provider Details

I. General information

NPI: 1982423208
Provider Name (Legal Business Name): SAMANTHA S SELF
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/03/2024
Last Update Date: 06/19/2026
Certification Date: 06/19/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1420 ROOSEVELT AVE STE 2
MOUNT VERNON WA
98273-2687
US

IV. Provider business mailing address

1420 ROOSEVELT AVE STE 2
MOUNT VERNON WA
98273-2687
US

V. Phone/Fax

Practice location:
  • Phone: 360-939-1450
  • Fax:
Mailing address:
  • Phone: 360-939-1450
  • Fax: 360-282-1203

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: