Provider Demographics
NPI:1154217222
Name:KERNISANT, SAMSON
Entity type:Individual
Prefix:
First Name:SAMSON
Middle Name:
Last Name:KERNISANT
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:425 PLEASANT ST STE 104
Mailing Address - Street 2:
Mailing Address - City:BROCKTON
Mailing Address - State:MA
Mailing Address - Zip Code:02301-2533
Mailing Address - Country:US
Mailing Address - Phone:508-269-9695
Mailing Address - Fax:508-425-3048
Practice Address - Street 1:425 PLEASANT ST STE 104
Practice Address - Street 2:
Practice Address - City:BROCKTON
Practice Address - State:MA
Practice Address - Zip Code:02301-2533
Practice Address - Country:US
Practice Address - Phone:508-269-9695
Practice Address - Fax:508-425-3048
Is Sole Proprietor?:No
Enumeration Date:2025-06-16
Last Update Date:2025-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program