Provider Demographics
NPI:1124576145
Name:SMITH, SAMANTHA LAUREN
Entity Type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:LAUREN
Last Name:SMITH
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 1:548 ALOSIO DR
Mailing Address - Street 2:
Mailing Address - City:RIVER VALE
Mailing Address - State:NJ
Mailing Address - Zip Code:07675-5579
Mailing Address - Country:US
Mailing Address - Phone:201-452-6427
Mailing Address - Fax:
Practice Address - Street 1:525 E 68TH ST
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10065-4870
Practice Address - Country:US
Practice Address - Phone:201-452-6427
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-09-19
Last Update Date:2016-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY602934367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered