Provider Demographics
NPI:1720845175
Name:MAGRUDER, SAMANTHA EMILY (FNP)
Entity type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:EMILY
Last Name:MAGRUDER
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:508 COTTONWOOD RD
Mailing Address - Street 2:
Mailing Address - City:FRANKFORT
Mailing Address - State:IL
Mailing Address - Zip Code:60423-1010
Mailing Address - Country:US
Mailing Address - Phone:708-969-1131
Mailing Address - Fax:
Practice Address - Street 1:5741 W CERMAK RD
Practice Address - Street 2:
Practice Address - City:CICERO
Practice Address - State:IL
Practice Address - Zip Code:60804-2129
Practice Address - Country:US
Practice Address - Phone:708-222-0100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-03-04
Last Update Date:2024-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL041470079163W00000X
IL209.029764363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse