| NPI | 1801480041 |
|---|---|
| Former Name | SAMANTHA JO WISNOM |
| Entity Type | Individual |
| Gender | Female |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: SC 25234) |
| Additional Taxonomies | 363LF0000X Nurse Practitioner, Family (Licence: SC 25234) |
| Enumeration Date | 2021-03-01 |
| Last Update Date | 2022-09-08 |