MEDICARE: SAMANTHA WILLIS FNP-C

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LF0000X	Family Nurse Practitioner	200411	LA

General Provider Information

NPI Number	:	1568175941
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SAMANTHA WILLIS FNP-C

Provider Business Mailing Address
First Line	:	12931 CARRINGTON PLACE AVE
Second Line	:
City	:	BATON ROUGE
State	:	LA
Zip	:	70817-1205
Country	:	US
Telephone Number	:	913-515-0300
Fax Number	:

Provider Business Practice Location Address
First Line	:	18448 MAGNOLIA BRIDGE RD STE A&B
Second Line	:
City	:	GREENWELL SPRINGS
State	:	LA
Zip	:	70739-4626
Country	:	US
Telephone Number	:	225-256-0063
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/02/2023
Last Update Date	:	01/02/2023

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