Basic Information
| Provider Information | |||||||||
| NPI: | 1336686708 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ANDERSON | ||||||||
| FirstName: | SAMANTHA | ||||||||
| MiddleName: | BETH | ||||||||
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| Credential: | CNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1205 MCLAIN ST | ||||||||
| Address2: | |||||||||
| City: | NEWPORT | ||||||||
| State: | AR | ||||||||
| PostalCode: | 721123533 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8705238911 | ||||||||
| FaxNumber: | 8705123455 | ||||||||
| Practice Location | |||||||||
| Address1: | 1205 MCLAIN ST | ||||||||
| Address2: | |||||||||
| City: | NEWPORT | ||||||||
| State: | AR | ||||||||
| PostalCode: | 721123533 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8705238911 | ||||||||
| FaxNumber: | 8705123455 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/24/2017 | ||||||||
| LastUpdateDate: | 08/16/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/16/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 216639 | AR | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 364SA2200X | S002305 | AR | N | Physician Assistants & Advanced Practice Nursing Providers | Clinical Nurse Specialist | Adult Health |
ID Information
| ID | Type | State | Issuer | Description | 218616758 | 05 | AR | MEDICAID |