MEDICARE: SAMANTHA JO STOVALL APRN, NP-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	A006267	AR

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1720648702
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SAMANTHA JO STOVALL APRN, NP-C

Provider Business Mailing Address
First Line	:	PO BOX 1848
Second Line	:
City	:	MENA
State	:	AR
Zip	:	71953-1841
Country	:	US
Telephone Number	:	479-437-3449
Fax Number	:	479-243-0285

Provider Business Practice Location Address
First Line	:	534 LUZERNE ST
Second Line	:
City	:	MOUNT IDA
State	:	AR
Zip	:	71957-9449
Country	:	US
Telephone Number	:	888-710-8220
Fax Number	:	866-573-0761

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

Provider Enumeration Date	:	06/20/2019
Last Update Date	:	05/27/2023

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