Provider Demographics
NPI:1134308604
Name:SAMUEL, ANNETTE (PHN)
Entity Type:Individual
Prefix:MS
First Name:ANNETTE
Middle Name:
Last Name:SAMUEL
Suffix:
Gender:F
Credentials:PHN
Other - Prefix:MS
Other - First Name:ANNETTE
Other - Middle Name:
Other - Last Name:SAMUEL
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 21506
Mailing Address - Street 2:
Mailing Address - City:EL SOBRANTE
Mailing Address - State:CA
Mailing Address - Zip Code:94820-1506
Mailing Address - Country:US
Mailing Address - Phone:510-758-1691
Mailing Address - Fax:
Practice Address - Street 1:1000 SAN LEANDRO BLVD
Practice Address - Street 2:
Practice Address - City:SAN LEANDRO
Practice Address - State:CA
Practice Address - Zip Code:94577-1598
Practice Address - Country:US
Practice Address - Phone:510-618-3389
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-31
Last Update Date:2007-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA350793163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse