Healthcare Provider Details

I. General information

NPI: 1790380558
Provider Name (Legal Business Name): SAMANTHA MARTY APRN-CNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/01/2020
Last Update Date: 10/19/2023
Certification Date: 10/19/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

47 CHAMBERS CIRCLE RD
WALKER WV
26180-3585
US

IV. Provider business mailing address

47 CHAMBERS CIRCLE RD
WALKER WV
26180-3585
US

V. Phone/Fax

Practice location:
  • Phone: 888-771-8372
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAPRN.CNP.0026794
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: