Provider Demographics
NPI:1407283294
Name:SAMUELS, INDIA
Entity Type:Individual
Prefix:
First Name:INDIA
Middle Name:
Last Name:SAMUELS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1525 S HIGLEY RD # 104-125
Mailing Address - Street 2:
Mailing Address - City:GILBERT
Mailing Address - State:AZ
Mailing Address - Zip Code:85296-4795
Mailing Address - Country:US
Mailing Address - Phone:480-442-4647
Mailing Address - Fax:
Practice Address - Street 1:460 N MESA DR
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85201-5973
Practice Address - Country:US
Practice Address - Phone:877-931-9142
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-10-11
Last Update Date:2022-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN28170338A363LF0000X
AZ253611363LF0000X, 363LP0808X
VA0024180647363LF0000X
IN71004709A363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily