Provider Demographics
NPI:1003268863
Name:BOGGS, SAMANTHA IRENE (LPN)
Entity Type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:IRENE
Last Name:BOGGS
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:31 CHRIS MATT CT
Mailing Address - Street 2:
Mailing Address - City:BAY SHORE
Mailing Address - State:NY
Mailing Address - Zip Code:11706-6731
Mailing Address - Country:US
Mailing Address - Phone:631-968-9196
Mailing Address - Fax:
Practice Address - Street 1:31 CHRIS MATT CT
Practice Address - Street 2:
Practice Address - City:BAY SHORE
Practice Address - State:NY
Practice Address - Zip Code:11706-6731
Practice Address - Country:US
Practice Address - Phone:631-968-9196
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-07-05
Last Update Date:2016-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY255708-1261QA0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA0600XAmbulatory Health Care FacilitiesClinic/CenterAdult Day Care