Provider Demographics
NPI:1053020867
Name:GLAVIN, SAMARA ALEXIS (PMHNP)
Entity type:Individual
Prefix:MRS
First Name:SAMARA
Middle Name:ALEXIS
Last Name:GLAVIN
Suffix:
Gender:F
Credentials:PMHNP
Other - Prefix:MRS
Other - First Name:SAMARA
Other - Middle Name:ALEXIS
Other - Last Name:GLAVIN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PMHNP-BC, MSN, RN
Mailing Address - Street 1:5512 NE 109TH CT STE I
Mailing Address - Street 2:
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98662-6175
Mailing Address - Country:US
Mailing Address - Phone:360-200-5273
Mailing Address - Fax:833-593-8274
Practice Address - Street 1:5512 NE 109TH CT STE I
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98662-6175
Practice Address - Country:US
Practice Address - Phone:360-200-5273
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-11-21
Last Update Date:2023-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAAP61403677363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health