Provider Demographics
NPI:1316635923
Name:CASSITY, SAMANTHA NICHOLE
Entity type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:NICHOLE
Last Name:CASSITY
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 1:2707 15TH PL
Mailing Address - Street 2:
Mailing Address - City:KENOSHA
Mailing Address - State:WI
Mailing Address - Zip Code:53140-4947
Mailing Address - Country:US
Mailing Address - Phone:262-551-2700
Mailing Address - Fax:
Practice Address - Street 1:2707 15TH PL
Practice Address - Street 2:
Practice Address - City:KENOSHA
Practice Address - State:WI
Practice Address - Zip Code:53140-4947
Practice Address - Country:US
Practice Address - Phone:262-551-2700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-05-01
Last Update Date:2023-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI13824363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI100242210Medicaid