MEDICARE: SAMANTHA S SELF

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	390200000X	Student in an Organized Health Care Education/Training Program		WA

General Provider Information

NPI Number	:	1982423208
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SAMANTHA S SELF

Provider Business Mailing Address
First Line	:	1420 ROOSEVELT AVE STE 2
Second Line	:
City	:	MOUNT VERNON
State	:	WA
Zip	:	98273-2687
Country	:	US
Telephone Number	:	360-939-1450
Fax Number	:	360-282-1203

Provider Business Practice Location Address
First Line	:	1420 ROOSEVELT AVE STE 2
Second Line	:
City	:	MOUNT VERNON
State	:	WA
Zip	:	98273-2687
Country	:	US
Telephone Number	:	360-939-1450
Fax Number	:

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

Provider Enumeration Date	:	10/03/2024
Last Update Date	:	06/19/2026

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