Provider Demographics
NPI:1073096582
Name:SAMUEL, ROSE MARIE
Entity Type:Individual
Prefix:
First Name:ROSE
Middle Name:MARIE
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 1:370 NTH 9TH STREET
Mailing Address - Street 2:
Mailing Address - City:LEBANON
Mailing Address - State:PA
Mailing Address - Zip Code:17046
Mailing Address - Country:US
Mailing Address - Phone:717-222-8617
Mailing Address - Fax:
Practice Address - Street 1:GALLUP INDIAN MEDICAL CENTER
Practice Address - Street 2:516 EAST NIZHONI BLVD
Practice Address - City:GALLUP
Practice Address - State:NM
Practice Address - Zip Code:87305
Practice Address - Country:US
Practice Address - Phone:717-222-8617
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-09-11
Last Update Date:2018-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA660697163WM0705X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WM0705XNursing Service ProvidersRegistered NurseMedical-Surgical