Provider Demographics
NPI:1992362859
Name:PHILLIPS, SAMANTHA JO (CRNA)
Entity type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:JO
Last Name:PHILLIPS
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:SAMANTHA
Other - Middle Name:JO
Other - Last Name:RICHARDSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CRNA
Mailing Address - Street 1:PO BOX 1108
Mailing Address - Street 2:
Mailing Address - City:CULLMAN
Mailing Address - State:AL
Mailing Address - Zip Code:35056-1108
Mailing Address - Country:US
Mailing Address - Phone:256-735-5041
Mailing Address - Fax:256-735-5003
Practice Address - Street 1:1912 AL HIGHWAY 157
Practice Address - Street 2:
Practice Address - City:CULLMAN
Practice Address - State:AL
Practice Address - Zip Code:35058-0609
Practice Address - Country:US
Practice Address - Phone:256-737-2639
Practice Address - Fax:256-737-2849
Is Sole Proprietor?:No
Enumeration Date:2019-05-24
Last Update Date:2020-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1-135895367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered