Provider Demographics
NPI:1104407691
Name:CHAMPION, SAMARA A (MSN, APRN, NP-C)
Entity type:Individual
Prefix:
First Name:SAMARA
Middle Name:A
Last Name:CHAMPION
Suffix:
Gender:F
Credentials:MSN, APRN, NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7834 TAYLOR RIDGE DR
Mailing Address - Street 2:
Mailing Address - City:DELTON
Mailing Address - State:MI
Mailing Address - Zip Code:49046-7806
Mailing Address - Country:US
Mailing Address - Phone:616-890-0087
Mailing Address - Fax:
Practice Address - Street 1:1550 CLINTON ST
Practice Address - Street 2:
Practice Address - City:MUSKEGON
Practice Address - State:MI
Practice Address - Zip Code:49442-5007
Practice Address - Country:US
Practice Address - Phone:231-737-1335
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-04-16
Last Update Date:2022-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704232661207Q00000X
MI4704232661NSA2109F363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1609451905Medicaid
MI1629066238Medicaid