Provider Demographics
NPI:1871291930
Name:STEPHENS, SAMANTHA JO (AGACNP-BC)
Entity type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:JO
Last Name:STEPHENS
Suffix:
Gender:F
Credentials:AGACNP-BC
Other - Prefix:
Other - First Name:SAMANTHA
Other - Middle Name:JO
Other - Last Name:MARTIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:AGACNP-BC
Mailing Address - Street 1:701 E COUNTY LINE RD STE 101
Mailing Address - Street 2:
Mailing Address - City:GREENWOOD
Mailing Address - State:IN
Mailing Address - Zip Code:46143-1070
Mailing Address - Country:US
Mailing Address - Phone:317-885-2860
Mailing Address - Fax:317-885-2869
Practice Address - Street 1:701 E COUNTY LINE RD STE 101
Practice Address - Street 2:
Practice Address - City:GREENWOOD
Practice Address - State:IN
Practice Address - Zip Code:46143-1070
Practice Address - Country:US
Practice Address - Phone:317-363-1316
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-02-20
Last Update Date:2024-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71014072A363L00000X, 363LA2200X, 363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN300080585Medicaid