=====================================================
General NPI Number Information
=====================================================
NPI Number | 1255905063
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SAMANTHA MOSHER GALSTER
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/17/2021
-----------------------------------------------------
Last Update Date | 05/17/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 310 S HARRIS RD
-----------------------------------------------------
City | PEARCY
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 71964-9665
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 501-416-7814
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 310 S HARRIS RD
-----------------------------------------------------
City | PEARCY
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 71964-9665
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 501-416-7814
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LP0808X
-----------------------------------------------------
Taxonomy Name | Psychiatric/Mental Health Nurse Practitioner
-----------------------------------------------------
License Number | 68220
-----------------------------------------------------
License Number State | ID
-----------------------------------------------------