Provider Demographics
NPI:1619710563
Name:JOHNSON, SAMANTHA FRESIA (CNP)
Entity type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:FRESIA
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:CNP
Other - Prefix:
Other - First Name:SAMANTHA
Other - Middle Name:
Other - Last Name:LYALL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:100 JACKSON PIKE
Mailing Address - Street 2:
Mailing Address - City:GALLIPOLIS
Mailing Address - State:OH
Mailing Address - Zip Code:45631-1560
Mailing Address - Country:US
Mailing Address - Phone:740-446-5000
Mailing Address - Fax:
Practice Address - Street 1:2131 E STATE ST
Practice Address - Street 2:
Practice Address - City:ATHENS
Practice Address - State:OH
Practice Address - Zip Code:45701-2138
Practice Address - Country:US
Practice Address - Phone:740-589-3100
Practice Address - Fax:740-566-4014
Is Sole Proprietor?:No
Enumeration Date:2024-06-18
Last Update Date:2025-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH0036739363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner