Provider Demographics
NPI:1407305337
Name:MCKNIGHT, SAMUELLA
Entity Type:Individual
Prefix:MS
First Name:SAMUELLA
Middle Name:
Last Name:MCKNIGHT
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 1:12442 S WALLACE ST
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60628-7128
Mailing Address - Country:US
Mailing Address - Phone:773-264-3057
Mailing Address - Fax:
Practice Address - Street 1:12442 S WALLACE ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60628-7128
Practice Address - Country:US
Practice Address - Phone:773-264-3057
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-10-04
Last Update Date:2016-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL043048239164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse