Provider Demographics
NPI:1154968667
Name:KACZMAREK, SAMANTHA MICHELLE (FNP-BC)
Entity type:Individual
Prefix:MRS
First Name:SAMANTHA
Middle Name:MICHELLE
Last Name:KACZMAREK
Suffix:
Gender:F
Credentials:FNP-BC
Other - Prefix:MISS
Other - First Name:SAMANTHA
Other - Middle Name:MICHELLE
Other - Last Name:JOHNSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:FNP-BC
Mailing Address - Street 1:888 W. BIG BEAVER RD. STE 900
Mailing Address - Street 2:
Mailing Address - City:TROY
Mailing Address - State:MI
Mailing Address - Zip Code:48084
Mailing Address - Country:US
Mailing Address - Phone:248-629-2880
Mailing Address - Fax:248-319-6493
Practice Address - Street 1:888 W. BIG BEAVER RD. STE 900
Practice Address - Street 2:
Practice Address - City:TROY
Practice Address - State:MI
Practice Address - Zip Code:48084
Practice Address - Country:US
Practice Address - Phone:248-629-2880
Practice Address - Fax:248-319-6493
Is Sole Proprietor?:Yes
Enumeration Date:2019-12-03
Last Update Date:2023-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704311772163W00000X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI14589057OtherCAQH