Provider Demographics
NPI:1043886153
Name:MASONGSONG, SAMANTHA LOUISE (FNP-BC)
Entity Type:Individual
Prefix:MISS
First Name:SAMANTHA
Middle Name:LOUISE
Last Name:MASONGSONG
Suffix:
Gender:F
Credentials:FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7575 SECOR RD
Mailing Address - Street 2:
Mailing Address - City:LAMBERTVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:48144-9624
Mailing Address - Country:US
Mailing Address - Phone:734-856-1800
Mailing Address - Fax:
Practice Address - Street 1:7575 SECOR RD
Practice Address - Street 2:
Practice Address - City:LAMBERTVILLE
Practice Address - State:MI
Practice Address - Zip Code:48144-9624
Practice Address - Country:US
Practice Address - Phone:734-856-1800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-05-29
Last Update Date:2022-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHAPRN.CNP.0029338363L00000X
MI04759660363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner