Provider Demographics
NPI:1346881000
Name:HARRELL, SAMUEL KEATING
Entity Type:Individual
Prefix:MR
First Name:SAMUEL
Middle Name:KEATING
Last Name:HARRELL
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 1:30 ARDALE ST
Mailing Address - Street 2:
Mailing Address - City:ROSLINDALE
Mailing Address - State:MA
Mailing Address - Zip Code:02131-1506
Mailing Address - Country:US
Mailing Address - Phone:301-602-0198
Mailing Address - Fax:
Practice Address - Street 1:624 WAVERLEY ST
Practice Address - Street 2:
Practice Address - City:FRAMINGHAM
Practice Address - State:MA
Practice Address - Zip Code:01702-6981
Practice Address - Country:US
Practice Address - Phone:508-504-1955
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-10-03
Last Update Date:2023-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MARN2319853163WG0000X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163WG0000XNursing Service ProvidersRegistered NurseGeneral Practice