Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 363LG0600X | Nurse Practitioner - Gerontology | 1125296 | KY |
NPI | 1053896563 |
---|---|
Provider Name | Samantha Jane Baker |
First Address | Radcliff, KY 40160-2604 |
Second Address | Radcliff, KY 40160-2604 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 01/10/2018 |
Last Update Date | 05/10/2018 |