Provider Demographics
NPI:1023022662
Name:SAMPSON, ELLEN E (NP)
Entity Type:Individual
Prefix:MS
First Name:ELLEN
Middle Name:E
Last Name:SAMPSON
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18 PRESTON RD
Mailing Address - Street 2:
Mailing Address - City:WEST ROXBURY
Mailing Address - State:MA
Mailing Address - Zip Code:02132-2815
Mailing Address - Country:US
Mailing Address - Phone:617-325-1054
Mailing Address - Fax:617-479-4555
Practice Address - Street 1:1261 FURNACE BROOK PKWY
Practice Address - Street 2:SUITE 31
Practice Address - City:QUINCY
Practice Address - State:MA
Practice Address - Zip Code:02169
Practice Address - Country:US
Practice Address - Phone:617-479-4545
Practice Address - Fax:617-479-4555
Is Sole Proprietor?:No
Enumeration Date:2006-07-28
Last Update Date:2009-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA172153363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0708020Medicaid
MANP0810Medicare ID - Type Unspecified
MAM20294Medicare ID - Type UnspecifiedGROUP #