Provider Demographics
NPI:1154133676
Name:FRALEY, SAMANTHA RENEE
Entity type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:RENEE
Last Name:FRALEY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 144
Mailing Address - Street 2:
Mailing Address - City:BIG ROCK
Mailing Address - State:VA
Mailing Address - Zip Code:24603-0144
Mailing Address - Country:US
Mailing Address - Phone:423-754-7768
Mailing Address - Fax:
Practice Address - Street 1:18765 RIVERSIDE DR
Practice Address - Street 2:
Practice Address - City:VANSANT
Practice Address - State:VA
Practice Address - Zip Code:24656
Practice Address - Country:US
Practice Address - Phone:276-935-2880
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-01-22
Last Update Date:2025-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024192519363LF0000X
VA0001246096163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily