Provider Demographics
NPI:1275091266
Name:SAMPSON, JEANNETTE JUDITH (FNP-C)
Entity Type:Individual
Prefix:MS
First Name:JEANNETTE
Middle Name:JUDITH
Last Name:SAMPSON
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:79 GLENRIDGE RD
Mailing Address - Street 2:
Mailing Address - City:GLENVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:12302-4523
Mailing Address - Country:US
Mailing Address - Phone:518-952-8368
Mailing Address - Fax:
Practice Address - Street 1:556 CLINTON AVE S
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14620-1105
Practice Address - Country:US
Practice Address - Phone:585-442-8422
Practice Address - Fax:585-442-8494
Is Sole Proprietor?:Yes
Enumeration Date:2019-03-08
Last Update Date:2024-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY707970163WC3500X, 163WG0600X, 163WM0705X
NYF346257363LF0000X, 363LF0000X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163WC3500XNursing Service ProvidersRegistered NurseCardiac Rehabilitation
No163WG0600XNursing Service ProvidersRegistered NurseGerontology
No163WM0705XNursing Service ProvidersRegistered NurseMedical-Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01420800Medicaid