Provider Demographics
NPI:1053366179
Name:MCCLUSKEY, SAMANTHA DANNETTE (ACNP)
Entity type:Individual
Prefix:MS
First Name:SAMANTHA
Middle Name:DANNETTE
Last Name:MCCLUSKEY
Suffix:
Gender:F
Credentials:ACNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1372 17 RD
Mailing Address - Street 2:
Mailing Address - City:FRUITA
Mailing Address - State:CO
Mailing Address - Zip Code:81521-9214
Mailing Address - Country:US
Mailing Address - Phone:970-314-3080
Mailing Address - Fax:970-257-2401
Practice Address - Street 1:2754 COMPASS DR STE 377
Practice Address - Street 2:
Practice Address - City:GRAND JUNCTION
Practice Address - State:CO
Practice Address - Zip Code:81506-8723
Practice Address - Country:US
Practice Address - Phone:970-314-3080
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-24
Last Update Date:2021-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO96665363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO500003975OtherRAILROAD
COC222118Medicare PIN
CO07966658Medicaid