Provider Demographics
NPI:1275979312
Name:LIEM, SAMANTHA KOZAK (NP)
Entity Type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:KOZAK
Last Name:LIEM
Suffix:
Gender:F
Credentials:NP
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 7630
Mailing Address - Street 2:
Mailing Address - City:GURNEE
Mailing Address - State:IL
Mailing Address - Zip Code:60031-7002
Mailing Address - Country:US
Mailing Address - Phone:847-244-6320
Mailing Address - Fax:
Practice Address - Street 1:1415 S ARLINGTON HEIGHTS RD
Practice Address - Street 2:
Practice Address - City:ARLINGTON HEIGHTS
Practice Address - State:IL
Practice Address - Zip Code:60005-3765
Practice Address - Country:US
Practice Address - Phone:847-439-1005
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-05-16
Last Update Date:2023-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209017903363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1275979312Medicaid
WI1275979312Medicaid
WI736012700Medicare PIN