Provider Demographics
NPI:1447789169
Name:THOMAS, SAMANTHA (FNP-BC)
Entity type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:
Last Name:THOMAS
Suffix:
Gender:F
Credentials:FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:109 E MAPLE ST
Mailing Address - Street 2:
Mailing Address - City:GILLESPIE
Mailing Address - State:IL
Mailing Address - Zip Code:62033-1473
Mailing Address - Country:US
Mailing Address - Phone:217-839-1526
Mailing Address - Fax:217-839-1538
Practice Address - Street 1:109 E MAPLE ST
Practice Address - Street 2:
Practice Address - City:GILLESPIE
Practice Address - State:IL
Practice Address - Zip Code:62033-1473
Practice Address - Country:US
Practice Address - Phone:217-839-1526
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-06-06
Last Update Date:2022-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209417465363L00000X
IL041417465163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163W00000XNursing Service ProvidersRegistered Nurse