Provider Demographics
NPI:1528638764
Name:JOHNSON, SAMANTHA LYNN (CRNA)
Entity type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:LYNN
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:SAMANTHA
Other - Middle Name:LYNN
Other - Last Name:DOWD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:22 BRAMHALL ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04102-3134
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:22 BRAMHALL ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04102-3134
Practice Address - Country:US
Practice Address - Phone:207-662-2526
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-29
Last Update Date:2024-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC288720163W00000X
NC6953367500000X
MERNA243058367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse