Provider Demographics
NPI:1437300076
Name:MAMBO, SAMIA EUNICE
Entity Type:Individual
Prefix:
First Name:SAMIA
Middle Name:EUNICE
Last Name:MAMBO
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 1:77 LAW ST
Mailing Address - Street 2:
Mailing Address - City:VALLEY STREAM
Mailing Address - State:NY
Mailing Address - Zip Code:11580-1017
Mailing Address - Country:US
Mailing Address - Phone:646-823-7843
Mailing Address - Fax:
Practice Address - Street 1:600 E 233RD ST
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10466-2604
Practice Address - Country:US
Practice Address - Phone:718-920-9507
Practice Address - Fax:718-920-9582
Is Sole Proprietor?:No
Enumeration Date:2008-10-01
Last Update Date:2020-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY450561163W00000X
NY079455367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse