Provider Demographics
NPI:1376885731
Name:SAMU, SHARECE D (LPN)
Entity Type:Individual
Prefix:
First Name:SHARECE
Middle Name:D
Last Name:SAMU
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11437 173RD ST
Mailing Address - Street 2:
Mailing Address - City:JAMAICA
Mailing Address - State:NY
Mailing Address - Zip Code:11434-1320
Mailing Address - Country:US
Mailing Address - Phone:718-421-4224
Mailing Address - Fax:
Practice Address - Street 1:11437 173RD ST
Practice Address - Street 2:
Practice Address - City:JAMAICA
Practice Address - State:NY
Practice Address - Zip Code:11434-1320
Practice Address - Country:US
Practice Address - Phone:718-421-4224
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-03-25
Last Update Date:2013-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY313280164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02386450Medicaid