Provider Demographics
NPI:1003379314
Name:SAMUEL, JAINA SABU
Entity Type:Individual
Prefix:
First Name:JAINA
Middle Name:SABU
Last Name:SAMUEL
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 1:49409 W CENTRAL PARK
Mailing Address - Street 2:
Mailing Address - City:SHELBY TWP
Mailing Address - State:MI
Mailing Address - Zip Code:48317-6355
Mailing Address - Country:US
Mailing Address - Phone:734-620-7933
Mailing Address - Fax:
Practice Address - Street 1:22101 MOROSS RD
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48236-2148
Practice Address - Country:US
Practice Address - Phone:313-343-4000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-04-12
Last Update Date:2024-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704247931163WM0705X, 363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
No163WM0705XNursing Service ProvidersRegistered NurseMedical-Surgical