Provider Demographics
NPI:1417268558
Name:SAMUEL, ANDREA NICOLE (MS, CCC-SLP)
Entity Type:Individual
Prefix:MRS
First Name:ANDREA
Middle Name:NICOLE
Last Name:SAMUEL
Suffix:
Gender:F
Credentials:MS, CCC-SLP
Other - Prefix:MISS
Other - First Name:ANDREA
Other - Middle Name:NICOLE
Other - Last Name:PATTERSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MS, CCC-SLP
Mailing Address - Street 1:4141 B ST STE 302
Mailing Address - Street 2:
Mailing Address - City:ANCHORAGE
Mailing Address - State:AK
Mailing Address - Zip Code:99503-5942
Mailing Address - Country:US
Mailing Address - Phone:907-887-6181
Mailing Address - Fax:907-646-1400
Practice Address - Street 1:4141 B ST STE 302
Practice Address - Street 2:
Practice Address - City:ANCHORAGE
Practice Address - State:AK
Practice Address - Zip Code:99503-5942
Practice Address - Country:US
Practice Address - Phone:907-887-6181
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-06-23
Last Update Date:2020-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK116235Z00000X
AKSLPS116235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AK1031235Medicaid