Provider Demographics
NPI:1902583917
Name:SAMANIEGO, ASHLEY (PMHNP-BC)
Entity type:Individual
Prefix:
First Name:ASHLEY
Middle Name:
Last Name:SAMANIEGO
Suffix:
Gender:F
Credentials:PMHNP-BC
Other - Prefix:
Other - First Name:ASHLEY
Other - Middle Name:
Other - Last Name:MITCHAM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN
Mailing Address - Street 1:1021 W OAKLAND AVE STE 310
Mailing Address - Street 2:
Mailing Address - City:JOHNSON CITY
Mailing Address - State:TN
Mailing Address - Zip Code:37604-2192
Mailing Address - Country:US
Mailing Address - Phone:423-952-2111
Mailing Address - Fax:423-282-1657
Practice Address - Street 1:2204 PAVILION DR STE 107
Practice Address - Street 2:
Practice Address - City:KINGSPORT
Practice Address - State:TN
Practice Address - Zip Code:37660-4651
Practice Address - Country:US
Practice Address - Phone:423-392-6100
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-06-30
Last Update Date:2024-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN180297163WP0808X
TN36562363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental Health