Provider Demographics
NPI:1386814721
Name:SAMUEL, KATHLEEN RUTH (LPN)
Entity Type:Individual
Prefix:MRS
First Name:KATHLEEN
Middle Name:RUTH
Last Name:SAMUEL
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 1:1480 E 48TH ST
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11234-3102
Mailing Address - Country:US
Mailing Address - Phone:718-253-1042
Mailing Address - Fax:860-449-1760
Practice Address - Street 1:450 MONTGOMERY ST
Practice Address - Street 2:APT. 2
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11225-3010
Practice Address - Country:US
Practice Address - Phone:718-778-0770
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-02-29
Last Update Date:2008-02-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY195673-1164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01972509Medicaid