Provider Demographics
NPI:1386471175
Name:MORENO, SAMANTHA LOUISE
Entity type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:LOUISE
Last Name:MORENO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:SAMANTHA
Other - Middle Name:MORENO
Other - Last Name:BOWLES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2041 PHILPOTT RD LOT 3
Mailing Address - Street 2:
Mailing Address - City:SOUTH BOSTON
Mailing Address - State:VA
Mailing Address - Zip Code:24592-6833
Mailing Address - Country:US
Mailing Address - Phone:956-801-9719
Mailing Address - Fax:
Practice Address - Street 1:2041 PHILPOTT RD LOT 3
Practice Address - Street 2:
Practice Address - City:SOUTH BOSTON
Practice Address - State:VA
Practice Address - Zip Code:24592-6833
Practice Address - Country:US
Practice Address - Phone:956-801-9719
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-09-17
Last Update Date:2024-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376J00000XNursing Service Related ProvidersHomemaker