Provider Demographics
NPI:1962250084
Name:ABBOTT, SAMANTHA GRACE (RN)
Entity type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:GRACE
Last Name:ABBOTT
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:950 OLDE FARM RD
Mailing Address - Street 2:
Mailing Address - City:TROY
Mailing Address - State:IL
Mailing Address - Zip Code:62294-3128
Mailing Address - Country:US
Mailing Address - Phone:618-670-9366
Mailing Address - Fax:
Practice Address - Street 1:1 HAIRPIN DRIVE
Practice Address - Street 2:
Practice Address - City:EDWARDSVILLE
Practice Address - State:IL
Practice Address - Zip Code:62026-0001
Practice Address - Country:US
Practice Address - Phone:618-650-5688
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-05-13
Last Update Date:2024-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program