Provider Demographics
NPI:1407145576
Name:LAU, SAMANTHA (NURSE PRACTITIONER)
Entity Type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:
Last Name:LAU
Suffix:
Gender:F
Credentials:NURSE PRACTITIONER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5551 HOLLYWOOD BLVD # 1050
Mailing Address - Street 2:
Mailing Address - City:HOLLYWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:90028-6814
Mailing Address - Country:US
Mailing Address - Phone:714-660-3932
Mailing Address - Fax:
Practice Address - Street 1:4949 S MACADAM AVE FL 2 #15
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97239-3912
Practice Address - Country:US
Practice Address - Phone:714-660-3932
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-03-29
Last Update Date:2021-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA665425363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health