=====================================================
General NPI Number Information
=====================================================
NPI Number | 1336686708
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SAMANTHA BETH ANDERSON CNP
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/24/2017
-----------------------------------------------------
Last Update Date | 08/16/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1205 MCLAIN ST
-----------------------------------------------------
City | NEWPORT
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 72112-3533
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 870-523-8911
-----------------------------------------------------
Fax | 870-512-3455
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1205 MCLAIN ST
-----------------------------------------------------
City | NEWPORT
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 72112-3533
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 870-523-8911
-----------------------------------------------------
Fax | 870-512-3455
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number | 216639
-----------------------------------------------------
License Number State | AR
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 364SA2200X
-----------------------------------------------------
Taxonomy Name | Adult Health Clinical Nurse Specialist
-----------------------------------------------------
License Number | S002305
-----------------------------------------------------
License Number State | AR
-----------------------------------------------------