Provider Demographics
NPI:1235533910
Name:SAM, ELIZABETH (REGISTERED NURSE)
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:
Last Name:SAM
Suffix:
Gender:F
Credentials:REGISTERED NURSE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 159
Mailing Address - Street 2:
Mailing Address - City:OWYHEE
Mailing Address - State:NV
Mailing Address - Zip Code:89832-0159
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1623 HOSPITAL LOOP
Practice Address - Street 2:
Practice Address - City:OWYHEE
Practice Address - State:NV
Practice Address - Zip Code:89832-1200
Practice Address - Country:US
Practice Address - Phone:775-757-2415
Practice Address - Fax:775-757-2066
Is Sole Proprietor?:Yes
Enumeration Date:2014-10-09
Last Update Date:2014-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NDR40849163WC1500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WC1500XNursing Service ProvidersRegistered NurseCommunity Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NDR40849OtherRN LICENSE