MEDICARE: SAMANTHA M BOCKUS LPN

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	164W00000X	Licensed Practical Nurse	025.0135891	VT

General Provider Information

NPI Number	:	1770249856
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SAMANTHA M BOCKUS LPN

Provider Business Mailing Address
First Line	:	93 REYNOLDS RD
Second Line	:
City	:	GRAND ISLE
State	:	VT
Zip	:	05458-2121
Country	:	US
Telephone Number	:	802-393-2401
Fax Number	:

Provider Business Practice Location Address
First Line	:	93 REYNOLDS RD
Second Line	:
City	:	GRAND ISLE
State	:	VT
Zip	:	05458-2121
Country	:	US
Telephone Number	:	802-393-2401
Fax Number	:

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

Provider Enumeration Date	:	11/12/2021
Last Update Date	:	11/12/2021

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