Provider Demographics
NPI:1487364667
Name:PRIBULA, SAMANTHA
Entity type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:
Last Name:PRIBULA
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 1:5476 DIANA LYNN DR
Mailing Address - Street 2:
Mailing Address - City:STOW
Mailing Address - State:OH
Mailing Address - Zip Code:44224-1649
Mailing Address - Country:US
Mailing Address - Phone:330-696-4021
Mailing Address - Fax:
Practice Address - Street 1:155 HERITAGE WOODS DR
Practice Address - Street 2:
Practice Address - City:COPLEY
Practice Address - State:OH
Practice Address - Zip Code:44321-2791
Practice Address - Country:US
Practice Address - Phone:330-666-0980
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-11-29
Last Update Date:2022-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHAPRN.CNP.0032563207Q00000X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine