MEDICARE: SAMANTHA BLAKESLEE NP

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	0024179636	VA

General Provider Information

NPI Number	:	1750990511
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SAMANTHA BLAKESLEE NP

Provider Business Mailing Address
First Line	:	43599 BARRETTS SQ
Second Line	:
City	:	ASHBURN
State	:	VA
Zip	:	20147-7013
Country	:	US
Telephone Number	:	585-729-7578
Fax Number	:

Provider Business Practice Location Address
First Line	:	13031 LEE JACKSON HWY
Second Line	:
City	:	FAIRFAX
State	:	VA
Zip	:	22033-2050
Country	:	US
Telephone Number	:	703-378-7550
Fax Number	:

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

Provider Enumeration Date	:	07/28/2020
Last Update Date	:	07/28/2020

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