Provider Demographics
NPI:1386885291
Name:HETRICK, SAMANTHA HETRICK (LPN)
Entity type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:HETRICK
Last Name:HETRICK
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10253 W OLD LINCOLN WAY
Mailing Address - Street 2:
Mailing Address - City:WOOSTER
Mailing Address - State:OH
Mailing Address - Zip Code:44691-9368
Mailing Address - Country:US
Mailing Address - Phone:330-464-8182
Mailing Address - Fax:
Practice Address - Street 1:10253 W OLD LINCOLN WAY
Practice Address - Street 2:
Practice Address - City:WOOSTER
Practice Address - State:OH
Practice Address - Zip Code:44691-9368
Practice Address - Country:US
Practice Address - Phone:330-464-8182
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-03-23
Last Update Date:2011-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH132641164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse