Healthcare Provider Details

I. General information

NPI: 1851017966
Provider Name (Legal Business Name): SAMANTHA JO NAMLIK FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: SAMANTHA JO HENRY

II. Dates (important events)

Enumeration Date: 10/19/2022
Last Update Date: 10/19/2022
Certification Date: 10/06/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

800 WHEELING AVE
GLEN DALE WV
26038-1660
US

IV. Provider business mailing address

632 COOPER LN
PROCTOR WV
26055-1375
US

V. Phone/Fax

Practice location:
  • Phone: 304-845-3211
  • Fax:
Mailing address:
  • Phone: 304-280-1767
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number114666
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: