Provider Demographics
NPI:1538767355
Name:DATES, SAMANTHA JO
Entity type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:JO
Last Name:DATES
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:N8273 E FRIESLAND RD
Mailing Address - Street 2:
Mailing Address - City:RANDOLPH
Mailing Address - State:WI
Mailing Address - Zip Code:53956-9407
Mailing Address - Country:US
Mailing Address - Phone:920-296-7067
Mailing Address - Fax:
Practice Address - Street 1:N8273 E FRIESLAND RD
Practice Address - Street 2:
Practice Address - City:RANDOLPH
Practice Address - State:WI
Practice Address - Zip Code:53956-9407
Practice Address - Country:US
Practice Address - Phone:920-296-7067
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-10-14
Last Update Date:2020-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI325608164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse