Provider Demographics
NPI:1538728704
Name:MAYO, SAMANTHA GRACE (CRNA)
Entity type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:GRACE
Last Name:MAYO
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5 2ND RD
Mailing Address - Street 2:
Mailing Address - City:HOPKINTON
Mailing Address - State:MA
Mailing Address - Zip Code:01748-2731
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:55 LAKE AVE N
Practice Address - Street 2:
Practice Address - City:WORCESTER
Practice Address - State:MA
Practice Address - Zip Code:01655-0002
Practice Address - Country:US
Practice Address - Phone:508-334-3271
Practice Address - Fax:508-856-5911
Is Sole Proprietor?:No
Enumeration Date:2019-06-11
Last Update Date:2021-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MARN2298184367500000X, 163WC0200X
NH068205-21163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse
No163WC0200XNursing Service ProvidersRegistered NurseCritical Care Medicine