Provider Demographics
NPI:1053137596
Name:NIETO, SAMANTHA
Entity type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:
Last Name:NIETO
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 1:1304 JIM PAUL DR
Mailing Address - Street 2:
Mailing Address - City:EL PASO
Mailing Address - State:TX
Mailing Address - Zip Code:79936-7248
Mailing Address - Country:US
Mailing Address - Phone:915-478-7868
Mailing Address - Fax:
Practice Address - Street 1:3401 JOE BATTLE BLVD
Practice Address - Street 2:
Practice Address - City:EL PASO
Practice Address - State:TX
Practice Address - Zip Code:79936-2791
Practice Address - Country:US
Practice Address - Phone:915-849-8567
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-11-30
Last Update Date:2024-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX75056183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist